The Relationship Between Alexithymia and Emotional Awareness: A Meta-Analytic Review of the Correlation Between TAS-20 and LEAS

Psychological Treatments for Alexithymia: A Systematic Review

Alexithymia, a psychological condition characterized by emotional suppression, is positively correlated with depression and anxiety and can develop into various mental disorders. Although alexithymia affects 10% of the symptomatic population and 25% of psychiatric patients, there has been a paucity of intervention studies. Even though several effective psychological treatments, including cognitive behavioral therapy (CBT), have been tested in recent years, there is a lack of comprehensive reviews on their efficacy. The objectives of this systematic review were to explore and synthesize findings from recent randomized controlled trials (RCTs) about psychological treatments, with the following inclusion criteria: (1) published from 2010 to 2024; (2) full text being available in English; (3) peer-reviewed journals; and (4) baselines and outcomes measured by TAS-20 and raw data were provided. We excluded non-psychological studies and studies involving mindfulness and DBT. We searched electronic databases (PubMed, PsycInfo, and Google Scholar) and found 18 RCTs and 21 arms for alexithymia, with a combined total of 1251 participants. Fourteen arms (67%) investigated the effect of CBT on alexithymia, including acceptance and commitment therapy (seven arms), behavioral activation therapy (two arms), schema therapy, and compassion-focused therapy. The results indicated that most psychological interventions significantly decreased TAS-20, illustrating a showcase of treatments from each trial with different effect sizes (within-intervention group, ranging from 0.41 to 13.25). However, due to the heterogeneity between the studies, this review study may not be conclusive enough to make each intervention standardized. Further high-quality RCTs with larger sample sizes and more consistent methodologies are needed, and corrective findings from such studies should be applied to produce more robust evidence-based psychological interventions for treating alexithymia.

Emotion word repertoire in the adult attachment interview is linked to reduced suicide attempts in patients with borderline personality disorder

Background

This study explored the association between emotion word repertoire (EWR), attachment, reflective functioning and personality organization (PO) and suicidal behavior in borderline personality disorder (BPD) patients.

Methods

The current study performed a secondary data analysis from a randomized control trial for BPD patients (all female; n = 87; age: m = 27; SD = 7.42). EWR was assessed via machine-scoring transcripts of Adult Attachment Interviews (AAI) for affective words using the VETA electronic scoring software for the Levels of Emotional Awareness Scale (LEAS). Generated scores were related to impairments in PO (Structured Interview for Personality Organization; STIPO), attachment organization (AAI) and mentalization (Reflective Functioning Scale), general symptom severity (Brief Symptom Inventory; BSI-53), self-harm and suicidal behavior. Independent effects of the investigated predictors were studied using Bayesian path analysis.

Results

Corrected for education, findings in Bayesian path analysis suggest an independent negative association between EWR and suicide attempts (BE = -.32; 95 % CI [-.51, -.12]) and positive associations of deficits in PO with psychiatric symptoms (BE = .23; 95 % CI [.01, .44]) as well as suicide attempts (BE = .30; 95 % CI [.08, .49]).

Discussion

The findings underscore the potential role of high EWR and PO as a protective factor for suicidal behavior in individuals with BPD.

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.

Capacity of Generative AI to Interpret Human Emotions From Visual and Textual Data: Pilot Evaluation Study

BACKGROUND

Mentalization, which is integral to human cognitive processes, pertains to the interpretation of one's own and others' mental states, including emotions, beliefs, and intentions. With the advent of artificial intelligence (AI) and the prominence of large language models in mental health applications, questions persist about their aptitude in emotional comprehension. The prior iteration of the large language model from OpenAI, ChatGPT-3.5, demonstrated an advanced capacity to interpret emotions from textual data, surpassing human benchmarks. Given the introduction of ChatGPT-4, with its enhanced visual processing capabilities, and considering Google Bard's existing visual functionalities, a rigorous assessment of their proficiency in visual mentalizing is warranted.

OBJECTIVE

The aim of the research was to critically evaluate the capabilities of ChatGPT-4 and Google Bard with regard to their competence in discerning visual mentalizing indicators as contrasted with their textual-based mentalizing abilities.

METHODS

The Reading the Mind in the Eyes Test developed by Baron-Cohen and colleagues was used to assess the models' proficiency in interpreting visual emotional indicators. Simultaneously, the Levels of Emotional Awareness Scale was used to evaluate the large language models' aptitude in textual mentalizing. Collating data from both tests provided a holistic view of the mentalizing capabilities of ChatGPT-4 and Bard.

RESULTS

ChatGPT-4, displaying a pronounced ability in emotion recognition, secured scores of 26 and 27 in 2 distinct evaluations, significantly deviating from a random response paradigm (P<.001). These scores align with established benchmarks from the broader human demographic. Notably, ChatGPT-4 exhibited consistent responses, with no discernible biases pertaining to the sex of the model or the nature of the emotion. In contrast, Google Bard's performance aligned with random response patterns, securing scores of 10 and 12 and rendering further detailed analysis redundant. In the domain of textual analysis, both ChatGPT and Bard surpassed established benchmarks from the general population, with their performances being remarkably congruent.

CONCLUSIONS

ChatGPT-4 proved its efficacy in the domain of visual mentalizing, aligning closely with human performance standards. Although both models displayed commendable acumen in textual emotion interpretation, Bard's capabilities in visual emotion interpretation necessitate further scrutiny and potential refinement. This study stresses the criticality of ethical AI development for emotional recognition, highlighting the need for inclusive data, collaboration with patients and mental health experts, and stringent governmental oversight to ensure transparency and protect patient privacy.

Impaired emotional awareness is associated with childhood maltreatment exposure and positive symptoms in schizophrenia

Objectives

Evidence suggests that emotional awareness-the ability to identify and label emotions-may be impaired in schizophrenia and related to positive symptom severity. Exposure to childhood maltreatment is a risk factor for both low emotional awareness and positive symptoms.

Methods

The current investigation examines associations between a performance-based measure of emotional awareness, positive symptom severity, and childhood maltreatment exposure in 44 individuals with a schizophrenia-spectrum disorder and 48 healthy comparison participants using the electronic Levels of Emotional Awareness Scale (eLEAS), Positive and Negative Syndrome Scale (PANSS) and Childhood Trauma Questionnaire (CTQ).

Results

Patients demonstrated significant deficits in emotional awareness overall, which was true for both self and others. In patients, lower emotional awareness was significantly associated with more severe positive symptoms. Emotional awareness was significantly impaired in patients with schizophrenia with self-reported maltreatment exposure, relative to other groups. Severity of maltreatment was not significantly associated with emotional awareness or positive symptoms when looking continuously, and there was no significant indirect effect.

Conclusion

These data suggest that emotional awareness impairments observed in schizophrenia may be exacerbated by exposure to childhood maltreatment, possibly putting individuals at greater risk for experiencing positive symptoms of psychosis.

Identifying and regulating emotions after acquired brain injury: the role of interoceptive sensibility

Introduction

Interoceptive deficits are associated with difficulties in identifying and regulating emotions. However, research on interoception after acquired brain injury (ABI) is scarce, and its relationship with emotional difficulties in this population is unknown. This study aimed to (1) examine differences in self-reported alexithymia, performance-based emotional awareness, emotion regulation, depression, and interoceptive sensibility between ABI and control individuals; and (2) analyze the role of adaptive interoceptive dimensions in these emotional processes after ABI.

Methods

Forty-three individuals with ABI and 42 matched control individuals completed the Multidimensional Assessment of Interoceptive Awareness-2, the Toronto Alexithymia Scale, the Levels of Emotional Awareness Scale, the Difficulties in Emotion Regulation Scale, and the Hospital Anxiety and Depression Scale.

Results

Compared to the control group, individuals with ABI showed reduced tendency to ignore unpleasant sensations increased severity of depressive symptoms, as well as tendencies to have greater difficulties in emotion regulation and lower emotional awareness. Additionally, interoceptive dimensions such as trusting, as well as not-distracting from and not-worrying about bodily sensations, played a relevant role in explaining lower alexithymia and difficulties in emotion regulation. Moreover, lower alexithymia and emotion dysregulation were related to less depressive symptoms. These relationships were invariant across ABI and control individuals.

Discussion

Although individuals with ABI may have different levels of emotional abilities compared to non-ABI individuals, the relationship patterns between interoceptive and emotional processes appear to be similar between the two groups. This study suggests the potential benefit of addressing both interoceptive and emotional difficulties in treatments targeting such prevalent sequelae of ABI as depressive symptoms.

ChatGPT outperforms humans in emotional awareness evaluations

The artificial intelligence chatbot, ChatGPT, has gained widespread attention for its ability to perform natural language processing tasks and has the fastest-growing user base in history. Although ChatGPT has successfully generated theoretical information in multiple fields, its ability to identify and describe emotions is still unknown. Emotional awareness (EA), the ability to conceptualize one's own and others' emotions, is considered a transdiagnostic mechanism for psychopathology. This study utilized the Levels of Emotional Awareness Scale (LEAS) as an objective, performance-based test to analyze ChatGPT's responses to twenty scenarios and compared its EA performance with that of the general population norms, as reported by a previous study. A second examination was performed one month later to measure EA improvement over time. Finally, two independent licensed psychologists evaluated the fit-to-context of ChatGPT's EA responses. In the first examination, ChatGPT demonstrated significantly higher performance than the general population on all the LEAS scales (Z score = 2.84). In the second examination, ChatGPT's performance significantly improved, almost reaching the maximum possible LEAS score (Z score = 4.26). Its accuracy levels were also extremely high (9.7/10). The study demonstrated that ChatGPT can generate appropriate EA responses, and that its performance may improve significantly over time. The study has theoretical and clinical implications, as ChatGPT can be used as part of cognitive training for clinical populations with EA impairments. In addition, ChatGPT's EA-like abilities may facilitate psychiatric diagnosis and assessment and be used to enhance emotional language. Further research is warranted to better understand the potential benefits and risks of ChatGPT and refine it to promote mental health.

Socioemotional self- and co-regulation in functional seizures: comparing high and low posttraumatic stress

Functional seizures (FS) are seizure-like symptoms without electroencephalogram (EEG)-based epileptic activity. Those with FS often show emotion-related dysfunction and disrupted interpersonal relationships, in which posttraumatic stress disorder symptoms (PTS) may play a role. We sought to better understand trauma comorbidities and socioemotional processes in FS, including affectionate touch, a form of social connection linked to emotion regulation and awareness. We administered questionnaires online to a community sample of 89 trauma-exposed FS participants (FS diagnoses were self-reported), 51 with and 38 without clinical-level PTS (FS-PTShi, FS-PTSlo) and 216 seizure-free matched trauma-exposed controls (TCs), 91 with and 125 without clinical-level PTS (TC-PTShi, TC-PTSlo) per the Posttraumatic Stress Disorder Symptom Checklist (PCL). As hypothesized, both FS-PTShi and FS-PTSlo reported more emotional avoidance (Brief Experiential Avoidance Questionnaire), more emotion regulation difficulties (Difficulties in Emotion Regulation Scale), and more perceived stress (Perceived Stress Scale) than PTS-matched counterparts. FS-PTShi also reported less reappraisal (Emotion Regulation Questionnaire), more loneliness (UCLA Loneliness Scale), and less frequent affectionate touch (Physical Affection Scale) during waking and surrounding sleep than TC-PTShi, whereas FS-PTSlo and TC-PTSlo did not differ. Neither FS group differed from PTS-matched controls in emotion suppression (Emotion Regulation Questionnaire) or comfort with social touch (Social Touch Questionnaire). Among FS, FS-PTShi reported more difficulties than FS-PTSlo on nearly all measures (non-significant trend for social support). Findings underscore potential synergistic effects of FS and PTS clinical symptoms in shaping experiences of one's emotions and social world, suggesting fostering meaningful connections with others, including via affectionate touch, is an important treatment target.

Development and validation of a computer program for measuring emotional awareness in German-The geLEAS (German electronic Levels of Emotional Awareness Scale)

Introduction

Emotional awareness is the ability to identify, interpret, and verbalize the emotional responses of oneself and those of others. The Levels of Emotional Awareness Scale (LEAS) is an objective performance inventory that accurately measures an individual's emotional awareness. LEAS assessments are typically scored manually and are therefore both time consuming and cognitively demanding. This study presents a German electronic scoring program for the LEAS (geLEAS), the first non-English computerized assessment approach of the LEAS.

Methods

Data were collected from a healthy German community sample (N = 208). We developed a modern software for computerizing LEAS scoring, an open-source text-based emotion assessment tool called VETA (Verbal Emotion in Text Assessment). We investigated if the software would arrive at similar results as hand scoring in German and if emotional awareness would show similar associations to sociodemographic information and psychometric test results as in previous studies.

Results

The most frequently used scoring method of the geLEAS shows excellent internal consistency (α = 0.94) and high correlations with hand scoring (r = 0.97, p < 0.001). Higher emotional awareness measured by the geLEAS is associated with female gender, older age, and higher academic achievement (all p < 0.001). Moreover, it is linked to the ability to identify emotions in facial expressions (p < 0.001) and more accurate theory of mind functioning (p < 0.001).

Discussion

An automated method for evaluating emotional awareness greatly expands the ability to study emotional awareness in clinical care and research. This study aims to advance the use of emotional awareness as a clinical and scientific parameter.

A systematic review on the links between emotion regulation difficulties and obsessive-compulsive disorder

BACKGROUND

Growing evidence suggests a link between emotion regulation (ER) deficits and obsessive-compulsive symptoms (OCS).

AIMS

A systematic review was conducted to integrate empirical research on the nature of ER difficulties associated with obsessive-compulsive disorder (OCD), validated measures of ER for OCD and evidence base for psychological interventions targeting ER difficulties in OCD.

METHODS

Database searches were conducted on CINAHL, Cochrane Library, EMBASE, MEDLINE, PUBMED, PsycINFO and Scopus with keywords related to ER and OCD. 2609 articles were found, six were identified from other sources and 21 studies were included in this review. The review was registered on PROSPERO (CDR42020184076).

RESULTS

The non-acceptance of emotions was the most consistently related to OCS - albeit not uniformly with all OCS dimensions. There was also some evidence suggesting that difficulties in impulse-control, accessing effective ER strategies and engaging in goal-directed behaviours to be related to OCS. No OCD-specific ER measure was identified. Interventions with ER components appeared to be promising for the treatment of OCD.

FUTURE DIRECTIONS

Recommendations on how to build on the existing literature and improve the quality of evidence were provided.

Prevalence and correlates of alexithymia in older persons with medically (un)explained physical symptoms

OBJECTIVES

Much is unknown about the combination of Medically Unexplained Symptoms (MUS) and alexithymia in later life, but it may culminate in a high disease burden for older patients. In the present study we assess the prevalence of alexithymia in older patients with either MUS or Medically Explained Symptoms (MES) and we explore physical, psychological and social correlates of alexithymia.

METHODS AND DESIGN

A case control study was performed. We recruited older persons (>60 years) with MUS (N = 118) or MES (N = 154) from the general public, general practitioner clinics and hospitals. Alexithymia was measured by the 20-item Toronto Alexithymia Scale, correlates were measured by various questionnaires.

RESULTS

Prevalence and severity of alexithymia were higher among older persons with MUS compared to MES. Alexithymia prevalence in the MUS subgroup was 23.7%. We found no association between alexithymia and increasing age. Alexithymia was associated with depressive symptoms, especially in the MUS population.

CONCLUSIONS

Alexithymia prevalence was lower than generally found in younger patients with somatoform disorder, but comparable to studies with similar diagnostic methods for MUS. Considering the high prevalence and presumed etiological impact of alexithymia in older patients with MUS, as well as its association with depression, this stresses the need to develop better understanding of the associations between alexithymia, MUS and depression in later life.

Associations Between Autism Symptomatology, Alexithymia, Trait Emotional Intelligence, and Adjustment to College

It has been asserted that the socio-emotional challenges associated with autism spectrum disorder (ASD) may be explained, in part, by the higher rates of alexithymia in individuals with autism. Alexithymia refers to difficulties in identifying one's own emotional states and describing those states to others. Thus, one goal of the present study was to examine levels of alexithymia in relation to ASD symptomatology and trait emotion intelligence (EI). Trait EI is a multifaceted concept that captures emotional competencies and behavioral dispositions A second goal was to assess whether alexithymia, ASD symptomatology and trait EI served as significant predictors of adjustment to college, including academic, social, and personal-emotional adjustment. In addition to keeping with the spectrum nature of autism, our research strategy allowed us to capture those students who may not have received a formal diagnosis of ASD but report symptoms that can be indicative of ASD. This includes women, who are less likely to receive a diagnosis of ASD even when ASD symptomatology is present. The results of the study showed that students reporting higher levels of ASD symptomatology also reported significantly higher levels of alexithymia and lower trait emotional intelligence (trait EI) than those with less or no symptomatology. Alexithymia was also negatively related to trait EI, and both alexithymia and ASD symptomatology were found to be significant predictors of trait EI. However, only trait EI was a significant predictor of adjustment to college and only for social adjustment. These findings suggest that support programs that develop trait EI skills may improve the college experience for students with ASD, regardless of alexithymia or ASD symptomatology.

The Value of Thinking About Feelings Across Cultures: A Preliminary Investigation of the Mentalizing Values Scale

In this proof-of-concept paper, we aimed to conduct a preliminary investigation of a newly developed scale that focuses on what we have termed “mentalizing values”—that is, the extent to which thinking about internal mental states is valued across different cultures. To this end, we report the results of a cross-cultural comparison of mentalizing values, Schwartz’s value dimensions, and two overlapping concepts: externally oriented thinking (EOT) and emotional awareness (EA), in a sample of students from Japan, the UK, and Israel ( N = 360). The results indicate that the mentalizing values scale (MVS) has good internal consistency in different languages and seems to capture a similar unidimensional construct across the three cultures. In Israel, people ranked mentalizing values as very important for them relative to other values, whereas in Japan, mentalizing values were relatively less important to people. In the UK, the relative importance of mentalizing values was between that assigned by their counterparts from Israel and Japan. EOT and EA were predicted by mentalizing values and by conservation across cultures, with mentalizing values explaining cultural differences over and above conservation, and mentalizing values being the only significant predictor within each culture. Finally, a parallel mediation model indicated that cultural differences in EOT and EA could be explained by mentalizing values and conservation. Overall, these findings lend initial support for the utility of the MVS and suggest that cultural variations in mentalizing values can be heavily intertwined with concepts that emphasize people’s tendency or capacity to think about feelings, such as EOT and EA.

Higher emotional awareness is associated with greater domain-general reflective tendencies

The tendency to reflect on the emotions of self and others is a key aspect of emotional awareness (EA)—a trait widely recognized as relevant to mental health. However, the degree to which EA draws on general reflective cognition vs. specialized socio-emotional mechanisms remains unclear. Based on a synthesis of work in neuroscience and psychology, we recently proposed that EA is best understood as a learned application of domain-general cognitive processes to socio-emotional information. In this paper, we report a study in which we tested this hypothesis in 448 (125 male) individuals who completed measures of EA and both general reflective cognition and socio-emotional performance. As predicted, we observed a significant relationship between EA measures and both general reflectiveness and socio-emotional measures, with the strongest contribution from measures of the general tendency to engage in effortful, reflective cognition. This is consistent with the hypothesis that EA corresponds to the application of general reflective cognitive processes to socio-emotional signals.

Meta-Analysis of the Associations Among Constructs of Intrapersonal Emotion Knowledge

To better define the boundaries of conceptually overlapping constructs of intrapersonal emotion knowledge (EK), we examined meta-analytic correlations among five intrapersonal EK-related constructs (affect labelling, alexithymia, emotional awareness, emotional clarity, emotion differentiation) and attention to emotion. Affect labelling, alexithymia, and emotional clarity were strongly associated, and they were moderately associated with attention to emotion. Alexithymia and emotional awareness were weakly associated, and emotion differentiation was unrelated with emotional clarity. Sample characteristics and measures moderated some of the associations. Publication bias was not found, except for the alexithymia-emotional awareness association. This study helped to clarify the extent to which similarly defined constructs overlap or are distinct, which can inform our decision to adequately label important constructs and employ corresponding measures.

Expertise in emotion: A scoping review and unifying framework for individual differences in the mental representation of emotional experience

Expertise refers to outstanding skill or ability in a particular domain. In the domain of emotion, expertise refers to the observation that some people are better at a range of competencies related to understanding and experiencing emotions, and these competencies may help them lead healthier lives. These individual differences are represented by multiple constructs including emotional awareness, emotional clarity, emotional complexity, emotional granularity, and emotional intelligence. These constructs derive from different theoretical perspectives, highlight different competencies, and are operationalized and measured in different ways. The full set of relationships between these constructs has not yet been considered, hindering scientific progress and the translation of findings to aid mental and physical well-being. In this article, we use a scoping review procedure to integrate these constructs within a shared conceptual space. Scoping reviews provide a principled means of synthesizing large and diverse literature in a transparent fashion, enabling the identification of similarities as well as gaps and inconsistencies across constructs. Using domain-general accounts of expertise as a guide, we build a unifying framework for expertise in emotion and apply this to constructs that describe how people understand and experience their own emotions. Our approach offers opportunities to identify potential mechanisms of expertise in emotion, encouraging future research on those mechanisms and on educational or clinical interventions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

[Common foundation of alexithymia and expressive suppression]

Hintergrund

Internationale Studien konnten bereits einen Zusammenhang zwischen Alexithymie und expressiver Suppression belegen. Im deutschsprachigen Raum wurde dieser Zusammenhang bisher nur sehr selten betrachtet. Übergeordnetes Ziel der vorliegenden Studie war die Untersuchung eines korrelativen und faktoriellen Zusammenhangs von Alexithymie und expressiver Suppression.

Material und Methoden

Insgesamt 317 Personen nahmen einer Onlinebefragung teil. Mithilfe der deutschsprachigen Versionen der Toronto Alexithymia Scale-26 (TAS-26) und des Emotion Regulation Questionnaire (ERQ) wurden Daten zu Alexithymie und expressiver Suppression erfasst.

Ergebnisse

Es bestanden signifikante Korrelationen zwischen der Subskala „Schwierigkeit bei der Identifikation von Gefühlen“ der TAS-26 und der Skala „Unterdrückung“ des ERQ (r = 0,5; p < 0,001) sowie zwischen der Subskala „Schwierigkeit bei der Beschreibung von Gefühlen“ der TAS-26 und der Skala „Unterdrückung“ des ERQ (r = 0,64; p < 0,001). Die Ergebnisse einer explorativen Faktorenanalyse ergaben eine Zwei-Faktoren-Lösung mit einem gemeinsamen Faktor für die TAS-26-Subskalen „Schwierigkeit bei der Identifikation von Gefühlen“ und „Schwierigkeit bei der Beschreibung von Gefühlen“ und der Skala „Unterdrückung“ des ERQ mit einer gemeinsamen Varianz von 38,2 % (χ² = 363,843; p < 0,001; Kaiser-Meyer-Olkin[KMO]-Wert = 0,699).

Schlussfolgerung

Die Ergebnisse legen nahe, dass den Skalen der TAS-26 in den Komponenten „Schwierigkeit bei der Identifikation von Gefühlen“ und „Schwierigkeit bei der Beschreibung von Gefühlen“ sowie der Skala „Unterdrückung“ des ERQ in der Komponente der „expressiven Suppression“ ein gemeinsames Konstrukt zugrunde liegt, das mit dem Begriff der Sprachlosigkeit belegt werden kann.

Levels of Emotional Awareness: Theory and Measurement of a Socio-Emotional Skill

Emotional awareness is the ability to conceptualize and describe one's own emotions and those of others. Over thirty years ago, a cognitive-developmental theory of emotional awareness patterned after Piaget's theory of cognitive development was created as well as a performance measure of this ability called the Levels of Emotional Awareness Scale (LEAS). Since then, a large number of studies have been completed in healthy volunteers and clinical populations including those with mental health or systemic medical disorders. Along the way, there have also been further refinements and adaptations of the LEAS such as the creation of a digital version in addition to further advances in the theory itself. This review aims to provide a comprehensive summary of the evolving theoretical background, measurement methods, and empirical findings with the LEAS. The LEAS is a reliable and valid measure of emotional awareness. Evidence suggests that emotional awareness facilitates better emotion self-regulation, better ability to navigate complex social situations and enjoy relationships, and better physical and mental health. This is a relatively new but promising area of research in the domain of socio-emotional skills. The paper concludes with some recommendations for future research.

Effectiveness of NoiBene: A Web-based programme to promote psychological well-being and prevent psychological distress in university students

Mental health problems are very common among university students. NoiBene is an evidence-based intervention for the promotion of well-being and the prevention of psychological distress among university students. NoiBene was tested in two studies. In study 1, a randomized controlled pilot trial was conducted to investigate the efficacy of NoiBene on students' well-being, emotional awareness, emotion regulation and assertiveness. The degree of satisfaction with the intervention was also investigated. Students (n = 24) were assigned to either the NoiBene programme or a control condition. In study 2, to confirm the usefulness of NoiBene, we analysed data from the current use of NoiBene (n = 178). The effectiveness of NoiBene on transdiagnostic mechanisms (perfectionism, repetitive thinking and experiential avoidance) was also investigated. In study 1, NoiBene improved self-acceptance and increased the ability to identify feelings. Students reported a good level of perceived usefulness. In study 2, the results confirmed findings from the first study and suggested that NoiBene can improve emotional awareness and decrease transdiagnostic mechanisms. NoiBene is a promising tool that can improve students' psychological well-being. More control studies are mandatory.

Affective agnosia: a core affective processing deficit in the alexithymia spectrum

Affective agnosia, an impairment in knowing how one feels emotionally, has been described as an extreme deficit in the experience and expression of emotion that may confer heightened risk for adverse medical outcomes. Alexithymia, by contrast, has been proposed as an over-arching construct that includes a spectrum of deficits of varying severity, including affective agnosia at the more severe end. This perspective has been challenged by Taylor and colleagues, who argue that the concept of affective agnosia is unnecessary. We compare these two perspectives by highlighting areas of agreement, reasons for asserting the importance of the affective agnosia concept, errors in Taylor and colleagues’ critique, and measurement issues. The need for performance-based measures of the ability to mentally represent emotional states in addition to metacognitive measures is emphasized. We then draw on a previously proposed three-process model of emotional awareness that distinguishes affective response generation, conceptualization and cognitive control processes which interact to produce a variety of emotional awareness and alexithymia phenotypes - including affective agnosia. The tools for measuring these three processes, their neural substrates, the mechanisms of brain-body interactions that confer heightened risk for adverse medical outcomes, and the differential treatment implications for different kinds of deficits are described. By conceptualizing alexithymia as a spectrum of deficits, the opportunity to match specific deficit mechanisms with personalized treatment for patients will be enhanced.

Development and validation of the Korean version of the Reading the Mind in the Eyes Test

The Reading the Mind in the Eyes Test (RMET) is one of the most widely used instruments for assessing the ability to recognize emotion. To examine the psychometric properties of the Korean version of the RMET and to explore the possible implications of poor performance on this task, 200 adults aged 19–32 years completed the RMET and the Korean version of the 20-item Toronto Alexithymia Scale (TAS-20K), the cognitive empathy domain of the Korean version of the Interpersonal Reactivity Index (IRI-C), and the Buss-Durkee Hostility Inventory-Aggression (BDHI-A). In the present study, confirmatory factor analyses confirmed that the hypothesized three-factor solution based on three different emotional valences of the items (positive, negative, or neutral) had a good fit to the data. The Korean version of the RMET also showed good test-retest reliability over a 4-week time interval. Convergent validity was also supported by significant correlations with subscales of the TAS-20K, and discriminant validity was identified by nonsignificant associations with IRI-C scores. In addition, no difference was found in RMET performance according to the sex of the photographed individuals or the sex or educational attainment of the participants. Individuals with poor RMET performance were more likely to experience alexithymia and aggression. The current findings will facilitate not only future research on emotion processing but also the assessment of conditions related to the decreased ability to decode emotional stimuli.

Alexithymia may explain the relationship between autistic traits and eating disorder psychopathology

BACKGROUND

Autistic people are disproportionately vulnerable to anorexia nervosa and other eating disorders (ED), and within the general population, autistic traits correlate with ED psychopathology. A putative mechanism which may underpin this heightened risk is alexithymia, a difficulty identifying and describing emotional states which is observed in both autism and ED. In two experiments with independent non-clinical samples, we explored whether alexithymia might mediate the heightened risk of eating psychopathology in individuals high in autistic traits.

METHODS

Our first experiment used the PROCESS macro for SPSS to examine relationships between alexithymia (measured by the Toronto Alexithymia Scale (TAS-20)), autistic traits (autism quotient (AQ)), and eating psychopathology (Eating Attitudes Test (EAT-26)) in 121 participants. Our second experiment (n = 300) replicated and furthered this analysis by examining moderating effects of sex and controlling for anxiety and depression as covariates. We also included an additional performance-based measure of alexithymia, the Levels of Emotional Awareness Scale (LEAS).

RESULTS

Study 1 suggested that TAS-20 scores mediated the relationship between heightened autistic traits and eating psychopathology. Replication and further scrutiny of this finding, in study 2, revealed that this mediation effect was partial and specific to the female participants in this sample. The mediation effect appeared to be carried by the difficulty identifying feelings subscale of the TAS-20, even when depression and anxiety were controlled for. LEAS scores, however, were not significantly related to autistic traits or eating psychopathology.

LIMITATIONS

Cross-sectional data prevents any conclusions around the direction and causality of relationships between alexithymia, autistic traits, and eating psychopathology (alongside depression and anxiety), necessitating longitudinal research. Our non-clinical sample was predominantly Caucasian undergraduate students, so it remains to be seen if these results would extrapolate to clinical and/or autistic samples. Divergence between the TAS-20 and LEAS raises crucial questions regarding the construct validity of these measures.

CONCLUSIONS

Our findings with respect to autistic traits suggest that alexithymia could partially explain the prevalence of ED in autistic people and may as such be an important consideration in the pathogenesis and treatment of ED in autistic and non-autistic people alike. Further research with clinical samples is critical to explore these ideas. Differences between men and women, furthermore, emphasize the importance of looking for sex-specific as well as generic risk factors in autistic and non-autistic men and women.

The effect of alexithymia and depressive feelings on pain perception in somatoform pain disorder

OBJECTIVE

To investigate the relationship between alexithymia and depression and their influence on the subjective versus experimental pain perception in somatoform pain disorder.

METHODS

Three groups consisting of 40 patients with somatoform pain disorder, 40 patients with depression, and 40 healthy controls were matched. They completed questionnaires regarding alexithymia (TAS26) and depressive feelings (BDI-II). In addition, pain patients rated their subjective pain intensity (NRS). Quantitative sensory testings were conducted in all participants examining temperature (CPT, HPT) and mechanical (MPT, PPT) thresholds.

RESULTS

Analysis of variance showed that alexithymia was significantly increased in both patient groups compared to healthy controls, but with the highest amount in somatoform pain. Regression analyses confirmed that this finding was in part due to a high comorbidity of depressive feelings in both patient groups. We found a discrepancy between increased clinical pain ratings and elevated pressure pain thresholds, indicating a less intense mechanical pain perception in somatoform pain. Correlation analyses demonstrated a significant connection of subjective pain ratings and pressure pain thresholds with depressive feelings.

CONCLUSION

Contrary to the results of other experimental pain studies on chronic muskuloskeletal pain syndromes, we could not confirm central sensitization in somatoform pain disorder. Our findings place the somatoform pain disorder more in the direction of affective disorder such as depression. These findings may improve a better understanding of the disease and also have direct therapeutic implications. The high occurrence of alexithymia and depressive feelings in somatoform pain should be considered in diagnostic and therapeutic regimens of these patients.

Orthorexic tendencies are linked with difficulties with emotion identification and regulation

BACKGROUND

Orthorexia nervosa (ON) is characterised by an unhealthy obsession with healthy eating and while it is not recognised as an eating disorder (or any disorder), current research is exploring similarities and differences with such disorders. The literature has shown that individuals with eating disorders have difficulties identifying and describing emotions (known as alexithymia) as well as regulating them. However no research to date has looked at whether people with orthorexic tendencies also suffer from difficulties with emotions. In this paper, we refer to people with orthorexic tendencies but do not assume that their healthy eating is at a pathological level needing clinical attention.

METHODS

The current study examined this by asking 196 healthy adults with an interest in healthy eating to complete four questionnaires to measure ON (ORTO-15 - reduced to ORTO-7CS), eating psychopathology (EAT-26), alexithymia (TAS-20) and emotion dysregulation (DERS-16).

RESULTS

We found that difficulties identifying and regulating emotions was associated with symptoms of ON, similar to what is found in other eating disorders. We suggest that ON behaviours may be used as a coping strategy in order to feel in control in these participants who have poor emotion regulation abilities.

CONCLUSIONS

Our results show that individuals with ON tendencies may share similar difficulties with emotions compared to other eating disorders. While important, our results are limited by the way we measured ON behaviours and we recommend that further research replicate our findings once a better and more specific tool is developed and validated to screen for ON characteristics more accurately.

The relationship between illness representations, alexithymia, coping strategies and subjective well-being among persons with asthma

BACKGROUND

In order to examine subjective well-being (SWB) among persons with asthma, most of the existing studies have focused on disease-related variables or concentrated on illness representations, alexithymia and coping, making it difficult to determine whether the relationship between illness representations, alexithymia, coping and SWB is just an artifact of the disease's severity.

OBJECTIVE

Based on the Self-Regulation Model, this study aimed to examine the interrelationships between the disease's characteristics (annual mean of asthma attacks, preventive treatment), illness representations, alexithymia, coping strategies and SWB among persons with asthma.

METHODS

A convenience sample of 208 persons with asthma completed measures of the disease's characteristics (annual mean of asthma attacks, preventive treatment), illness representations (identity, causes, timeline, consequences, control, coherence, emotional representations), alexithymia, coping strategies, SWB, and socio-demographic questionnaires. A hierarchical multiple regression was calculated with SWB as the dependent variable.

RESULTS

The regression model was found significant (F(14, 133) = 6.42, p < 0.001), explaining 34% of the variance in SWB. Higher levels of alexithymia, identity, cause and emotional representations and lower levels of control were related to lower levels of SWB. The addition of coping strategies did not add to the explained variance of SWB.

CONCLUSION

This study contributes to a better understanding of the determinants of SWB among persons with asthma. The findings indicate that clinical interventions targeting persons with asthma illness representations and alexithymia may assist persons with asthma to improve their SWB.

Emotional Awareness Correlated With Number of Awakenings From Polysomnography in Patients With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome-A Pilot Study

INTRODUCTION

Unrefreshing sleep is one of the diagnostic criteria in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), which could be explained by sleep disorders, for example obstructive sleep apnea, reported in our previous study with polysomnography. Our previous findings also indicate difficulties in emotional regulation when measuring alexithymia by TAS-20 (Toronto Alexithymia Scale) and level of emotional awareness by LEAS (Level of Emotional Awareness Scale) in ME/CFS patients. However, the reasons for this are unknown. The purpose of this study was to investigate correlations between data from subjective emotional regulation and polysomnography.

METHODS

Twenty-three ME/CFS patients (5 men and 18 women) of mean age 43, and 30 matched healthy controls (9 males and 21 women) of mean age 45, filled in TAS-20, LEAS, and Hospital Depression and Anxiety Scale (HADS). A polysomnography was performed on patients but not on healthy controls. Thus, values of normal population were used for sleep evaluation in ME/CFS patients.

RESULT

There were significant differences between patients and controls in several aspects of emotional regulation, for example LEAS-self and LEAS-total. Seventy percent of the patients had increased numbers of awakenings (shifts from any sleep stage to awake), 22% had obstructive sleep apneas, and 27% had periodic limb movements. Correlation analysis showed that number of awakenings significantly correlated with LEAS-self and LEAS-total, p < 0.01, respectively. There were no other significant correlations.

CONCLUSION

This pilot study demonstrated significant correlations between reduced emotional awareness and number of awakenings in polysomnography. Future studies with larger cohorts need to be conducted.

More Than Words Can Say: A Multi-Disciplinary Consideration of the Psychotherapeutic Evaluation and Treatment of Alexithymia

Alexithymia is a disorder that stands at the border of mind and body, with psychological/affective and physiological/experiential disturbances. The purpose of this article is to propose a new clinical access point for the evaluation and treatment of the deficits in emotional awareness demonstrated in alexithymia. This will be based on insights from recent neuroscientific research, which is adding to the psychodynamic understanding of alexithymia, regarding clinical presentation and etiology. Following a brief review of definitions, forms of measurement, and potential etiologic elements of alexithymia, current neuroscientific theory and research into "predictive processing" approaches to brain function will be outlined, including how "interoception" and "interoceptive inference" underpins emotion and emotional awareness. From this synergistic perspective, I will outline how interoceptive inference provides a key to the link between: problems in early life relational experiences and the patient's long held, but suboptimal models of their inner and outer world. This is reflected in the deficits in affective experiencing and emotional awareness described in alexithymia. Three clinical cases will be presented to illustrate this nuanced consideration of alexithymic etiology and treatment. The implications of the historical, psychological, and somatic aspects of experience will be considered, regarding the patients' diminished ability to: experience and represent emotional experience as distinct feeling states; signify the relevant meaning of affective experience; and incorporate such with cognitions to adaptively guide behavior. These will be addressed using psychometric, psychological, neuro-cognitive, and neurocomputational approaches. Elements from current theory, research, and treatment of alexithymia, will be highlighted that are salient to the clinician, in order to support their understanding of patients against the backdrop of current psychodynamic and neuroscientific research, which will thereby increase treatment options and benefits. The focus, and conclusion, of this article is the role that attention to interoception can play (within the safety of the therapeutic relationship and within any therapeutic process) in allowing updating of the patient's strongly held but dysfunctional beliefs.

Ecological momentary assessment of emotional awareness: Preliminary evaluation of psychometric properties

The Levels of Emotional Awareness Scale (LEAS) is a well-validated performance measure of trait emotional awareness (EA), which is associated with psychological and physical problems. EA is, however, expected to vary over time and we aimed to adapt the LEAS to permit the measurement of EA in daily life as a function of momentary state. Twenty-five students completed 12 ecological momentary assessments (EMAs) of EA across 2 days. The correlation between the mean EMAs of EA and trait EA, and the change over time in EA, was also examined. Findings revealed a significant positive correlation between state and trait EA. The within-person reliability was substantial, suggesting that EMAs can reliably assess EA over time across individuals. Importantly, latent state-trait analysis showed that about 50% of EA variability was due to state variance whereas only 2% of EA variability was due to trait variance. Preliminary psychometric properties suggest that the developed method allows for the measurement of EA in daily life and supports the claim that EA can be measured using both hypothetical (as in the LEAS) and real-life (using EMAs) scenarios.