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

Intolerance of Uncertainty and Anxiety (but not Alexithymia) Mediate the Association Between Autistic Traits and Quality of Life

Previous research has indicated that autistic individuals report lower quality of life (QoL) than non-autistic people. It is unclear whether it is the autism traits themselves or co-occurring thinking styles or mental health difficulties that most impair QoL. This study tested a hypothesised model to explore how 'intolerance of uncertainty' (IU), alexithymia (difficulty in identifying and describing own emotions), and anxiety play into the association between autistic traits and QoL. Online survey data were analysed from 116 autistic and 51 non-autistic adults who completed six standardised questionnaires measuring autistic traits, alexithymia, IU, anxiety and QoL (physical health, psychological health, social relations, and environment domains). The autistic group reported higher scores for alexithymia, IU and anxiety, and lower scores for QoL across domains, compared to the non-autistic group. Across the entire sample, autistic traits, alexithymia, IU and anxiety were positively correlated with one another, and negatively related to the four domains of QoL. Finally, IU and anxiety partially serially mediated the pathways from autistic traits to physical health and environment domains of QoL, and fully mediated the pathways from autistic traits to psychological health and social relations domains of QoL, across the full sample. The lower QoL experienced by autistic people may be explained in part by the mediating effect of both IU and anxiety (but not alexithymia). This study highlights the need for evidence-based interventions to address both IU and anxiety to improve QoL for autistic people/those with high levels of autistic traits.

Scene construction ability in neurotypical and autistic adults

LAY ABSTRACT

People with autism spectrum conditions (ASC) have difficulties imagining events, which might result from difficulty mentally generating and maintaining a coherent spatial scene. This study compared this scene construction ability between autistic (N = 55) and neurotypical (N = 63) adults. Results showed that scene construction was diminished in autistic compared to neurotypical participants, and participants with fewer autistic traits had better scene construction ability. ASC diagnosis did not influence the frequency of mentions of the self or of sensory experiences. Exploratory analysis suggests that scene construction ability is associated with the ability to understand our own and other people's mental states, and that these individual-level preferences/cognitive styles can overrule typical group-level characteristics.

The biosocial correlates and predictors of emotion dysregulation in autistic adults compared to borderline personality disorder and nonclinical controls

BACKGROUND

Emotion dysregulation (ED) is a core symptom of borderline personality disorder (BPD), whose aetiology has been attributed to biosocial factors. In autism spectrum condition (ASC), although ED is prevalent and is associated with decreased well-being (e.g. self-harm, suicidality), it has been understudied, especially in adults. It is therefore crucial to further understand ED in autistic adults to improve its treatment. Our study investigates ED, its behavioural correlates (e.g. self-harm, suicidality) and biosocial predictors in autistic adults relative to BPD and nonclinical controls (NC).

METHODS

A total of 724 participants (ASC = 154; BPD = 111; NC = 459) completed 11 self-reported questionnaires assessing ED, ASC and BPD traits, co-occurring disorders, alexithymia, emotional vulnerability and invalidating experiences (e.g. bullying, autistic camouflaging). The occurrence of ED behavioural correlates (i.e. self-harm, history of suicide attempts, and psychiatric hospitalizations) was collected. In addition, between-groups analyses, linear regressions and machine learning (ML) models were used to identify ED predictors in each group.

RESULTS

ED and its behavioural correlates were higher in ASC compared to NC, but milder than in BPD. While gender did not predict ED scores, autistic women had increased risk factors to ED, including sexual abuse and camouflaging. Interestingly, BPD traits, emotional vulnerability and alexithymia strongly predicted ED scores across the groups. Using ML models, sensory sensitivity and autistic camouflaging were associated with ED in ASC, and ADHD symptoms with ED in BPD.

LIMITATIONS

ASC and BPD diagnoses were self-reported, which did not allow us to check their accuracy. Additionally, we did not explore the transactional and the moderating/mediating relationships between the different variables. Moreover, our research is cross-sectional and cannot draw conclusions regarding the direction and causality of relationships between ED and other clinical dimensions.

CONCLUSIONS

ED and its behavioural correlates are heightened in BPD compared to ASC and nonclinical controls. In the ASC group, there were no gender differences in ED, despite the heightened exposure of autistic women to ED risk factors. BPD traits, emotional vulnerability, and alexithymia are core to ED regardless of diagnosis. Although less central, sensory sensitivity and autistic camouflaging seem to be specific predictors of ED in autistic adults.

Social Anxiety in Autistic People: Does the Clark and Wells Model fit?

PURPOSE

Cognitive behaviour therapy based on the Clark and Wells (1995) model is a first-line treatment for neurotypical people seeking support for social anxiety. While autistic people frequently report high social anxiety, it is unclear how appropriate the model is for this population.

METHODS

Over 300 autistic and non-autistic adults completed an online survey measuring key variables of the Clark and Wells model (socially-related negative thoughts, safety behaviours, self-focused attention). Using multiple regression and structural equation modelling, we assessed whether these variables accounted for the link between autism and social fears.

RESULTS

In multiple regression, autistic people experienced greater social fears than expected based on Clark and Wells variables, and safety behaviours were less predictive of social fears in autistic people. In structural equation modelling, Clark and Wells variables only mediated half the link between autistic traits and social fears. In exploratory analysis, we found that distress relating to uncertainty was an additional variable that needed to be taken into consideration in the relationship between autistic traits and social fears.

CONCLUSION

The Clark and Wells variables were relevant in autism, but did not fully explain elevated social fears in autistic people, which suggests that other factors are also important in accounting for social anxiety in autistic people. This means that therapy informed by the model may not be optimal for autistic people. We recommend further research developing adapted therapy for social anxiety in autistic people.

Prevalence of autistic traits in functional neurological disorder and relationship to alexithymia and psychiatric comorbidity

INTRODUCTION

In a cohort of adults with Functional Neurological Disorder (FND), we aim to: METHODS: 91 patients participating in a FND 5-week outpatient program completed baseline self-report questionnaires for total phobia, somatic symptom severity, attention deficit hyperactivity disorder (ADHD) and dyslexia. Patients were grouped by Autism Spectrum Quotient (AQ-10) score of <6 or ≥ 6 and compared for significant differences in tested variables. This analysis was repeated with patients grouped by alexithymia status. Simple effects were tested using pairwise comparisons. Multistep regression models tested direct relationships between autistic traits and psychiatric comorbidity scores, and mediation by alexithymia.

RESULTS

36 patients (40%) were AQ-10 positive (scoring ≥6 on AQ-10). A further 36 patients (across AQ-10 positive and AQ-10 negative groups) (40%) screened positive for alexithymia. AQ-10 positive patients scored significantly higher for alexithymia, depression, generalised anxiety, social phobia, ADHD, and dyslexia. Alexithymia positive patients scored significantly higher for generalised anxiety, depression, somatic symptoms severity, social phobia, and dyslexia. Alexithymia score was found to mediate the relationship between autistic trait and depression scores.

CONCLUSION

We demonstrate a high proportion of autistic and alexithymic traits, in adults with FND. A higher prevalence of autistic traits may highlight a need for specialised communication approaches in FND management. Mechanistic conclusions are limited. Future research could explore links with interoceptive data.

Characterizing Interoceptive Differences in Autism: A Systematic Review and Meta-analysis of Case-control Studies

Interoception, the body's perception of its own internal states, is thought to be altered in autism, though results of empirical studies have been inconsistent. The current study systematically reviewed and meta-analyzed the extant literature comparing interoceptive outcomes between autistic (AUT) and neurotypical (NT) individuals, determining which domains of interoception demonstrate robust between-group differences. A three-level Bayesian meta-analysis compared heartbeat counting performance, heartbeat discrimination performance, heartbeat counting confidence ratings, and self-reported interoceptive attention between AUT and NT groups (15 studies; n_AUT = 467, n_NT = 478). Autistic participants showed significantly reduced heartbeat counting performance [g = - 0.333, CrI_95% (- 0.535, - 0.138)] and higher confidence in their heartbeat counting abilities [g = 0.430, CrI_95% (0.123, 0.750)], but groups were equivalent on other meta-analyzed outcomes. Implications for future interoception research in autism are discussed.

Measuring subjective quality of life in autistic adults with the PROMIS global-10: Psychometric study and development of an autism-specific scoring method

LAY ABSTRACT

Quality of Life an outcome that both researchers and autistic advocates agree is extremely important to consider when implementing services, interventions, and supports for autistic people. However, there has been little research on the topic of how quality of life can best be measured in autistic people or whether existing quality of life questionnaires are appropriate for use in the autistic population. This study aimed to validate an established quality of life measure, the Patient-Reported Outcomes Measurement Information System Global-10, in a large sample of autistic adults recruited online. We created a new way to score the Patient-Reported Outcomes Measurement Information System Global-10 scale and generate a "General quality of life" score specific to autistic adults. This new score performed very well in this sample, showing very little measurement error and relating in expected ways to similar constructs, such as physical health and emotional distress. Exploratory analyses found that lower quality of life was associated with female sex and self-identification as a sexual or gender minority (i.e. LGBTQ + identity). These findings suggest that the new Patient-Reported Outcomes Measurement Information System Global-10 quality of life score is a reliable and valid measure of quality of life in autistic adults, although additional studies are necessary to further explore its measurement properties in other subsets of the autistic population, such as individuals with intellectual disabilities. This measure is freely available for use as an outcome in both research and clinical practice, and an online score calculator is available to support the use of this measure in real-world applications.

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

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

Psychometric validation of a brief self-report measure of misophonia symptoms and functional impairment: The duke-vanderbilt misophonia screening questionnaire

Misophonia is a newly described disorder of sound tolerance characterized by strong negative emotional reactions to specific "trigger" sounds, resulting in significant distress, pathological avoidance, and impairment in daily life. Research on misophonia is still in its infancy, and most existing psychometric tools for assessing misophonia symptoms have not been extensively validated. The purpose of the current study was to introduce and psychometrically validate the duke-vanderbilt Misophonia Screening Questionnaire (DVMSQ), a novel self-report measure of misophonia symptoms that can be used to determine misophonia "caseness" in clinical and research settings. Employing large online samples of general population adults (n = 1403) and adults on the autism spectrum (n = 936), we rigorously evaluated the internal structure, reliability, validity, and measurement invariance of the DVMSQ. Results indicated that 17 of the 20 original DVMSQ items fit well to a bifactor structure with one "general misophonia" factor and four specific factors (anger/aggression, distress/avoidance, impairment, and global impact). DVMSQ total and subscale scores were highly reliable in both general population and autistic adult samples, and the measure was found to be approximately invariant across age, sex, education level, and autism status. DVMSQ total scores also correlated strongly with another measure of misophonia symptoms (Duke Misophonia Questionnaire-Symptom Scale), with correlations between these two measures being significantly stronger than correlations between the DVMSQ and scales measuring other types of sound intolerance (Inventory of Hyperacusis Symptoms [General Loudness subscale] and DSM-5 Severity Measure for Specific Phobia [modified for phonophobia]). Additionally, DVMSQ items were used to operationalize diagnostic criteria for misophonia derived from the Revised Amsterdam Criteria, which were further updated to reflect a recent consensus definition of misophonia (published after the development of the DVMSQ). Using the new DVMSQ algorithm, 7.3% of general population adults and 35.5% of autistic adults met criteria for clinically significant misophonia. Although additional work is needed to further investigate the psychometric properties of the DVMSQ and validate its theory-based screening algorithm using best-estimate clinical diagnoses, this novel measure represents a potentially useful tool to screen for misophonia and quantify symptom severity and impairment in both autistic adults and the general population.

Alexithymia and intolerance of uncertainty predict somatic symptoms in autistic and non-autistic adults

LAY ABSTRACT

Autistic people have more physical health problems than non-autistic people. We were interested in whether autistic people experience more discomfort in their bodies than non-autistic people and whether certain psychological traits contribute to that. A survey was completed online by older adolescents and adults, 51 of whom were autistic, 32 of whom thought they might be autistic but were not diagnosed and 119 who were not autistic. They completed measures of somatic symptoms (daily experience of pain, discomfort, dizziness), alexithymia (difficulty identifying and expressing feelings), interoception (how much people are aware of their bodies) and intolerance of uncertainty (how people handle doubt or uncertainty), and reported any physical or mental health conditions. We found that the autistic participants had more physical and mental health conditions than the non-autistic participants, but even when we took account of this, they experienced higher levels of somatic symptoms. We looked at which psychological factors influenced levels of somatic symptoms across the whole sample, and found that alexithymia, intolerance of uncertainty, having physical health problems, being female and the number of mental health conditions predicted somatic symptoms, while interoception and autism diagnosis did not. The findings suggest that people may be more likely to experience physical discomfort if they are female, and have difficulty identifying and expressing feeling and difficulty tolerating doubt. As these psychological factors are more prominent in autism, we think this is important for physical and mental health providers to know about, so that these psychological factors can be considered when assessing and treating autistic people.

The role of alexithymia and autistic traits in predicting quality of life in an online sample

BACKGROUND

Autistic people tend to report poorer Quality of Life (QOL) than comparison groups, though some studies do report more optimistic findings. Higher autistic traits are also related to poorer QOL. However, the role of alexithymia in this relationship has not been explored.

METHOD

A total of 163 participants (N = 53 autistic and N = 111 comparison) consented to take part; however, 30 participants were excluded due to missing data (who did not differ from those who were retained on age, gender, education, employment, or living status), leaving a final sample of 133 (N = 42 Autistic and 91 Comparison participants). Demographic information (including age, gender) was collected, alongside self-report measures of autistic traits, mental health, alexithymia, and QOL. We estimated regression models based on pre-registered analysis, and we conducted exploratory network analyses.

RESULTS

Alexithymic traits did not predict QOL when controlling for covariates. Depression significantly predicted Physical, Psychological, and Social QOL. When examining the impact of just alexithymic traits and autistic traits, both were significantly associated with Physical and Psychological QOL. For participants with a low depression score, the correlation between alexithymia and QOL was strong; suggesting that depression occludes the association between alexithymia and QOL. Network analyses suggested that depression and anxiety exert direct effects on Physical and Psychological QOL, whereas alexithymia scores may influence Physical QOL via autistic traits.

CONCLUSION

In sum, depression is a pervasive negative predictor of multiple QOL domains. The role of alexithymia in predicting QOL dimensionally and categorically was not ruled out, given our exploratory analyses, we suggest that interventions which target alexithymia may positively impact QOL for those who score low on depressive symptoms.

Current and lifetime somatic symptom burden among transition-aged autistic young adults

Somatic symptoms are the most common cause of outpatient medical visits in the general population, yet their presence and severity in individuals on the autism spectrum has rarely been studied. We sought to assess the prevalence, impact, and clinical correlates of 14 commonly reported somatic symptoms in a sample of 290 transition-aged autistic young adults (mean [SD] age: 23.10 [2.38] years, range 18-26; 76.7% diagnosed with autism before age 18) recruited from the Simons Foundation SPARK participant pool. A modified version of the Patient Health Questionnaire-15 was used to assess somatic symptom prevalence/impact, along with measures of depression, anxiety, autistic traits, and quality of life. Somatic symptom burden was much higher in autistic young adults than previously reported in the general population. The most commonly reported current symptoms were fatigue (72.8%), sleep problems (69.0%), and menstrual problems (61.4% of females). Moderate or severe symptom levels were reported by 53.9% of females and 18.75% of males in our cohort, with the odds of females endorsing any given symptom being 2-4 times greater than males. Both individual symptoms and total symptom burden were related to higher levels of depression, anxiety, and autistic traits, along with lower quality of life. Despite little research on this topic previously, somatic symptoms are highly prevalent in autistic young adults, particularly women. Future research is needed to investigate links between somatic symptoms, medical and psychiatric morbidity, and health care utilization in the autistic population.