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1.  How Does Emotional Context Modulate Response Inhibition in Alexithymia: Electrophysiological Evidence from an ERP Study 
PLoS ONE  2012;7(12):e51110.
Background
Alexithymia, characterized by difficulties in identifying and describing feelings, is highly indicative of a broad range of psychiatric disorders. Several studies have also discovered the response inhibition ability impairment in alexithymia. However, few studies on alexithymic individuals have specifically examined how emotional context modulates response inhibition procedure. In order to investigate emotion cognition interaction in alexithymia, we analyzed the spatiao-temporal features of such emotional response inhibition by the approaches of event-related potentials and neural source-localization.
Method
The study participants included 15 subjects with high alexithymia scores on the 20-item Toronto Alexithymia Scale (alexithymic group) and 15 matched subjects with low alexithymia scores (control group). Subjects were instructed to perform a modified emotional Go/Nogo task while their continuous electroencephalography activities were synchronously recorded. The task includes 3 categories of emotional contexts (positive, negative and neutral) and 2 letters (“M” and “W”) centered in the screen. Participants were told to complete go and nogo actions based on the letters. We tested the influence of alexithymia in this emotional Go/Nogo task both in behavioral level and related neural activities of N2 and P3 ERP components.
Results
We found that negatively valenced context elicited larger central P3 amplitudes of the Nogo–Go difference wave in the alexithymic group than in the control group. Furthermore, source-localization analyses implicated the anterior cingulate cortex (ACC) as the neural generator of the Nogo-P3.
Conclusion
These findings suggest that difficulties in identifying feelings, particularly in negative emotions, is a major feature of alexithymia, and the ACC plays a critical role in emotion-modulated response inhibition related to alexithymia.
doi:10.1371/journal.pone.0051110
PMCID: PMC3515526  PMID: 23227242
2.  The alexithymic brain: the neural pathways linking alexithymia to physical disorders 
Alexithymia is a personality trait characterized by difficulties in identifying and describing feelings and is associated with psychiatric and psychosomatic disorders. The mechanisms underlying the link between emotional dysregulation and psychosomatic disorders are unclear. Recent progress in neuroimaging has provided important information regarding emotional experience in alexithymia. We have conducted three brain imaging studies on alexithymia, which we describe herein. This article considers the role of emotion in the development of physical symptoms and discusses a possible pathway that we have identified in our neuroimaging studies linking alexithymia with psychosomatic disorders. In terms of socio-affective processing, alexithymics demonstrate lower reactivity in brain regions associated with emotion. Many studies have reported reduced activation in limbic areas (e.g., cingulate cortex, anterior insula, amygdala) and the prefrontal cortex when alexithymics attempt to feel other people’s feelings or retrieve their own emotional episodes, compared to nonalexithymics. With respect to primitive emotional reactions such as the response to pain, alexithymics show amplified activity in areas considered to be involved in physical sensation. In addition to greater hormonal arousal responses in alexithymics during visceral pain, increased activity has been reported in the insula, anterior cingulate cortex, and midbrain. Moreover, in complex social situations, alexithymics may not be able to use feelings to guide their behavior appropriately. The Iowa gambling task (IGT) was developed to assess decision-making processes based on emotion-guided evaluation. When alexithymics perform the IGT, they fail to learn an advantageous decision-making strategy and show reduced activity in the medial prefrontal cortex, a key area for successful performance of the IGT, and increased activity in the caudate, a region associated with impulsive choice. The neural machinery in alexithymia is therefore activated more on the physiologic, motor-expressive level and less in the cognitive-experiential domains of the emotional response system. Affects may play an important role in alleviating intrinsic physiologic reactions and adapting to the environment. Deficient development of emotional neural structures may lead to hypersensitivity to bodily sensations and unhealthy behaviors, a possible mechanism linking alexithymia to psychosomatic disorders.
doi:10.1186/1751-0759-7-1
PMCID: PMC3563604  PMID: 23302233
Affect; Alexithymia; Emotional dysregulation; Neuroimaging; Psychosomatic disorders
3.  Altered resting state connectivity of the default mode network in alexithymia 
Alexithymia is a trait characterized by a diminished capacity to describe and distinguish emotions and to fantasize; it is associated with reduced introspection and problems in emotion processing. The default mode network (DMN) is a network of brain areas that is normally active during rest and involved in emotion processing and self-referential mental activity, including introspection. We hypothesized that connectivity of the DMN might be altered in alexithymia. Twenty alexithymic and 18 non-alexithymic healthy volunteers underwent a resting state fMRI scan. Independent component analysis was used to identify the DMN. Differences in connectivity strength were compared between groups. Within the DMN, alexithymic participants showed lower connectivity within areas of the DMN (medial frontal and temporal areas) as compared to non-alexithymic participants. In contrast, connectivity in the high-alexithymic participants was higher for the sensorimotor cortex, occipital areas and right lateral frontal cortex than in the low-alexithymic participants. These results suggest a diminished connectivity within the DMN of alexithymic participants, in brain areas that may also be involved in emotional awareness and self-referential processing. On the other hand, alexithymia was associated with stronger functional connections of the DMN with brain areas involved in sensory input and control of emotion.
doi:10.1093/scan/nss048
PMCID: PMC3427871  PMID: 22563009
alexithymia; connectivity; default mode network; fMRI; resting state
4.  The association of interoceptive awareness and alexithymia with neurotransmitter concentrations in insula and anterior cingulate 
Alexithymia and increased interoceptive awareness have been associated with affective disorders as well as with altered insula and anterior cingulate cortex (ACC) function. Brain imaging studies have demonstrated an association between neurotransmitter function and affective disorders as well as personality traits. Here, we first examined the relationship between alexithymic facets as assessed with the Toronto Alexithymia Scale (TAS-20) and interoceptive awareness (assessed with the Body Perception Questionnaire) in 18 healthy subjects. Second, we investigated their association with glutamate and gamma-aminobutyric acid (GABA) concentrations in the left insula and the ACC using 3-Tesla proton magnetic resonance spectroscopy. Behaviorally, we found a close association between alexithymia and interoceptive awareness. Furthermore, glutamate levels in the left insula were positively associated with both alexithymia and awareness of autonomic nervous system reactivity, while GABA concentrations in ACC were selectively associated with alexithymia. Although preliminary, our results suggest that increased glutamate-mediated excitatory transmission—related to enhanced insula activity—reflects increased interoceptive awareness in alexithymia. Suppression of the unspecific emotional arousal evoked by increased awareness of bodily responses in alexithymics might thus be reflected in decreased neuronal activity mediated by increased GABA concentration in ACC.
doi:10.1093/scan/nst058
PMCID: PMC4040102  PMID: 23596189
alexithymia; interoceptive awareness; neurotransmitter; proton magnetic resonance spectroscopy
5.  Alexithymia and anxiety in female chronic pain patients 
Objectives
Alexithymia is highly prevalent among chronic pain patients. Pain is a remarkable cause for high levels of chronic anxiety. The purpose of this study was to investigate the prevalence of alexithymia and to determine anxiety levels among DSM-IV somatoform pain disorder (chronic pain) female patients and to examine the relationship between alexithymia and the self-reporting of pain.
Methods
Thirty adult females (mean age: 34,63 ± 10,62 years), who applied to the outpatient psychiatry clinic at a public hospital with the diagnosis of chronic pain disorder (DSM-IV), were included in the study. Thirty seven healthy females (mean age: 34,46 ± 7,43 years), who matched for sociodemographic features with the patient group, consisted the control group. A sociodemographic data form, 26-item Toronto Alexithymia Scale (TAS-26), Spielberger Trait Anxiety Inventory (STAI) were administered to each subject and information was obtained on several aspects of the patients' pain, including intensity (measured by VAS), and duration.
Results
Chronic pain patients were found significantly more alexithymic than controls. There was a positive correlation between TAS-26 scores and the duration of pain. The alexithymic and nonalexithymic group did not differ in their perception of pain. Neither positive correlation nor significant difference was found between alexithymia and trait anxiety in pain patients.
Discussion
Alexithymia may be important in addressing the diversity of subjective factors involved in pain. The conceptualization of alexithymia as a personality trait as well as a secondary state reaction is underlined by our data.
doi:10.1186/1744-859X-5-13
PMCID: PMC1562423  PMID: 16911802
6.  Dealing with Feelings: Characterization of Trait Alexithymia on Emotion Regulation Strategies and Cognitive-Emotional Processing 
PLoS ONE  2009;4(6):e5751.
Background
Alexithymia, or “no words for feelings”, is a personality trait which is associated with difficulties in emotion recognition and regulation. It is unknown whether this deficit is due primarily to regulation, perception, or mentalizing of emotions. In order to shed light on the core deficit, we tested our subjects on a wide range of emotional tasks. We expected the high alexithymics to underperform on all tasks.
Method
Two groups of healthy individuals, high and low scoring on the cognitive component of the Bermond-Vorst Alexithymia Questionnaire, completed questionnaires of emotion regulation and performed several emotion processing tasks including a micro expression recognition task, recognition of emotional prosody and semantics in spoken sentences, an emotional and identity learning task and a conflicting beliefs and emotions task (emotional mentalizing).
Results
The two groups differed on the Emotion Regulation Questionnaire, Berkeley Expressivity Questionnaire and Empathy Quotient. Specifically, the Emotion Regulation Quotient showed that alexithymic individuals used more suppressive and less reappraisal strategies. On the behavioral tasks, as expected, alexithymics performed worse on recognition of micro expressions and emotional mentalizing. Surprisingly, groups did not differ on tasks of emotional semantics and prosody and associative emotional-learning.
Conclusion
Individuals scoring high on the cognitive component of alexithymia are more prone to suppressive emotion regulation strategies rather than reappraisal strategies. Regarding emotional information processing, alexithymia is associated with reduced performance on measures of early processing as well as higher order mentalizing. However, difficulties in the processing of emotional language were not a core deficit in our alexithymic group.
doi:10.1371/journal.pone.0005751
PMCID: PMC2685011  PMID: 19492045
7.  Neural activity during interoceptive awareness and its associations with alexithymia—An fMRI study in major depressive disorder and non-psychiatric controls 
Objective: Alexithymia relates to difficulties recognizing and describing emotions. It has been linked to subjectively increased interoceptive awareness (IA) and to psychiatric illnesses such as major depressive disorder (MDD) and somatization. MDD in turn is characterized by aberrant emotion processing and IA on the subjective as well as on the neural level. However, a link between neural activity in response to IA and alexithymic traits in health and depression remains unclear.
Methods: A well-established fMRI task was used to investigate neural activity during IA (heartbeat counting) and exteroceptive awareness (tone counting) in non-psychiatric controls (NC) and MDD. Firstly, comparing MDD and NC, a linear relationship between IA-related activity and scores of the Toronto Alexithymia Scale (TAS) was investigated through whole-brain regression. Secondly, NC were divided by median-split of TAS scores into groups showing low (NC-low) or high (NC-high) alexithymia. MDD and NC-high showed equally high TAS scores. Subsequently, IA-related neural activity was compared on a whole-brain level between the three independent samples (MDD, NC-low, NC-high).
Results: Whole-brain regressions between MDD and NC revealed neural differences during IA as a function of TAS-DD (subscale difficulty describing feelings) in the supragenual anterior cingulate cortex (sACC; BA 24/32), which were due to negative associations between TAS-DD and IA-related activity in NC. Contrasting NC subgroups after median-split on a whole-brain level, high TAS scores were associated with decreased neural activity during IA in the sACC and increased insula activity. Though having equally high alexithymia scores, NC-high showed increased insula activity during IA compared to MDD, whilst both groups showed decreased activity in the sACC.
Conclusions: Within the context of decreased sACC activity during IA in alexithymia (NC-high and MDD), increased insula activity might mirror a compensatory mechanism in NC-high, which is disrupted in MDD.
doi:10.3389/fpsyg.2015.00589
PMCID: PMC4444750  PMID: 26074827
major depressive disorder; alexithymia; interoceptive awareness; insula; sACC; interoception; fMRI; neuroimaging
8.  When parenting fails: alexithymia and attachment states of mind in mothers of female patients with eating disorders 
Frontiers in Psychology  2015;6:1145.
Introduction: In recent years alexithymia and attachment theory have been recognized as two parallel research lines trying to improve the information on the development and maintenance of eating disorders (EDs). However, no research has analyzed these constructs among patients’ families. In this study we compared alexithymia and attachment in mothers of patients with EDs and a control group. Further, we hypothesized that mothers of daughters with EDs with insecure and unresolved states of mind will reported high levels of alexithymia. Lastly, we explored the daughters’ evaluations of maternal alexithymia.
Methods: 45 mothers of ED women and 48 mothers of healthy controls (N = 93) matched for age and socio-demographic variables were administered by the Toronto Alexithymia Scale-20 (TAS-20) (S), while two sub-groups of “ED” mothers (n = 20) and “non-ED” ones (n = 22) were assessed by the Adult Attachment Interview (AAI). Moreover, the Observer Alexithymia Scale (OAS) was administered to the daughters for evaluating maternal alexithymia.
Results: Regarding alexithymia, no differences were found between ED and non-ED mothers according to the TAS-20, while ED mothers showed more unresolved AAI classifications than non-ED mothers. No correlations were found between the TAS-20 and the AAI. Lastly, ED mothers were evaluated more alexithymic by their daughters with the OAS than those in the control group, and their alexithymic traits were significantly correlated with dismissing states of mind (idealization and lack of memory) in the AAIs.
Discussion: Our results highlighted an interesting discrepancy among mothers with ED daughters between the low level of alexithymia provided by their self-reports and the high level of alexithymia observed by their daughters, although the OAS showed severe methodological limitations. Maternal attachment states of mind characterized by the lack of resolution of past losses could be connected to a confusing and incoherent quality of parenting.
doi:10.3389/fpsyg.2015.01145
PMCID: PMC4532914  PMID: 26321978
parenting; eating disorder; alexithymia; attachment states of mind; mothers
9.  Alexithymia in eating disorders: therapeutic implications 
A high percentage of individuals affected by eating disorders (ED) achieve incomplete recovery following treatment. In an attempt to improve treatment outcome, it is crucial that predictors of outcome are identified, and personalized care approaches established in line with new treatment targets, thus facilitating patient access to evidence-based treatments. Among the psychological factors proposed as predictors of outcome in ED, alexithymia is of outstanding interest. The objective of this paper is to undertake a systematic review of the literature relating to alexithymia, specifically in terms of the implications for treatment of ED. In particular, issues concerning the role of alexithymia as a predictor of outcome and as a factor to be taken into account in the choice of treatment will be addressed. The effect of treatments on alexithymia will also be considered. A search of all relevant literature published in English using PubMed, PsycINFO, and Scopus databases was carried out on the basis of the following keywords: alexithymia, anorexia nervosa, bulimia nervosa, eating disorders, and treatment; no time limits were imposed. Despite the clinical relevance of alexithymia, the number of studies published on the above cited aspects is somewhat limited, and these studies are largely heterogeneous and feature significant methodological weaknesses. Overall, data currently available mostly correlate higher levels of alexithymia with a less favorable outcome in ED. Accordingly, alexithymia is seen as a relevant treatment target with the aim of achieving recovery of these patients. Treatments focusing on improving alexithymic traits, and specifically those targeting emotions, seem to show greater efficacy, although alexithymia levels often remain high even after specific treatment. Further investigations are needed to overcome the methodological limitations of previous studies, to understand the actual impact of alexithymia on ED outcome, and to allow more precise implications for treatment to be drawn. Additional research should also be undertaken to specify which of the alexithymic dimensions are specifically relevant to the course and outcome of ED, and to identify treatment protocols producing a significantly greater efficacy in ED patients with relevant alexithymic traits.
doi:10.2147/PRBM.S52656
PMCID: PMC4278740  PMID: 25565909
anorexia nervosa; bulimia nervosa; treatment
10.  Sense of alexithymia in patients with anxiety disorders comorbid with recurrent urticaria 
Aim
Alexithymia is associated with limited cognitive processing of emotions by an individual suffering from recurrent urticaria and alexithymia and makes them focus on somatic manifestations of emotional arousal and on poorly controlled compulsive reactions to negative stimulation. Alexithymia is considered to be a personality trait, which, along with other factors, predisposes individuals toward developing somatic diseases. The aim of the study was to assess the measurement of alexithymic features in patients with recurrent urticaria and to assess the types of concurrent anxiety disorders and overall anxiety level.
Methods
In order to diagnose clinical anxiety symptoms in patients, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the Hamilton Anxiety Rating Scale were applied. Alexithymic features were measured by means of a shortened version of the Toronto Alexithymia Scale, characterized by high discrimination power, internal coherence, and reliability.
Results
According to the Toronto Alexithymia Scale results, the greatest contributing factor was “inability to differentiate between feelings and bodily sensations”. This was observed in both males and females. Most frequently, the patients were found to suffer from generalized anxiety disorder and social phobia.
Conclusion
Alexithymia may result from the difficulty associated with expressing emotions caused by anxiety disorders. Undergoing treatment for anxiety disorders may contribute to reduced exacerbation of urticaria.
doi:10.2147/NDT.S94600
PMCID: PMC4844460  PMID: 27143899
alexithymia; anxiety; recurrent urticaria
11.  Eating disordered patients: personality, alexithymia, and implications for primary care. 
BACKGROUND: Eating disorders are becoming more apparent in primary care. Descriptions of character traits related to people with eating disorders are rarely reported in the primary care literature and there is little awareness of the implications of alexithymia--a concept that defines the inability to identify or express emotion. We hypothesised that many individuals with active eating disorders have alexithymic traits and a tendency to somatize their distress. AIM: To analyse the character traits and degree of alexithymia of a selected group of women with active eating disorders and in recovery, and to recommend responses by members of the primary care team that might meet the needs of such individuals. METHOD: Letters were sent to 200 female members of the Eating Disorders Association who had agreed to participate in research. Seventy-nine women volunteered to complete four postal questionnaires. This gave a response rate of 38.5%. Responders were categorised into three groups--anorexic, bulimic, and recovered--using the criteria of the Eating Disorders Inventory (EDI-2). The results of the 16PF5 Personality Inventory (16PF5) and the Toronto Alexithymia Scale (TAS-20) were analysed using one-way analysis of variance (ANOVA) and correlated using Pearson's correlation. A biographical questionnaire was also completed. RESULTS: In all three subgroups, high scores were achieved on the 16PF5 on 'apprehension and social sensitivity', while there were significant differences in the scores for 'privateness': a scale that measures the ability to talk about feelings and confide in others. On the TAS-20, 65% of the anorexic and 83% of the bulimic group scored in the alexithymic range compared with 33% of the recovered group. There was a significant negative correlation between alexithymia and social skills such as 'social and emotional expressivity' on the 16PF5. CONCLUSION: The results of this study emphasise the difference between those with active eating disorders who achieved high scores for privacy, introversion, and alexithymia, and those who have recovered. These character traits give potential helpers an important indication of the areas that can both block and facilitate recovery, and they act as a reminder that the presenting symptoms in eating disorders and other psychosomatic conditions are the outward presentation of internal conflict. It is suggested that effective screening and needs assessment will facilitate a more appropriate and prompt therapeutic response. This may be provided in the primary care setting where appropriate training has occurred.
PMCID: PMC1313605  PMID: 10695062
12.  Alexithymia Is Associated with Greater Risk of Chronic Pain and Negative Affect and with Lower Life Satisfaction in a General Population: The Hisayama Study 
PLoS ONE  2014;9(3):e90984.
Introduction
Chronic pain is a significant health problem worldwide, with a prevalence in the general population of approximately 40%. Alexithymia — the personality trait of having difficulties with emotional awareness and self-regulation — has been reported to contribute to an increased risk of several chronic diseases and health conditions, and limited research indicates a potential role for alexithymia in the development and maintenance of chronic pain. However, no study has yet examined the associations between alexithymia and chronic pain in the general population.
Methods
We administered measures assessing alexithymia, pain, disability, anxiety, depression, and life satisfaction to 927 adults in Hisayama, Japan. We classified the participants into four groups (low-normal alexithymia, middle-normal alexithymia, high-normal alexithymia, and alexithymic) based on their responses to the alexithymia measure. We calculated the risk estimates for the criterion measures by a logistic regression analysis.
Results
Controlling for demographic variables, the odds ratio (OR) for having chronic pain was significantly higher in the high-normal (OR: 1.49, 95% CI: 1.07–2.09) and alexithymic groups (OR: 2.56, 95% CI: 1.47–4.45) compared to the low-normal group. Approximately 40% of the participants belonged to these two high-risk groups. In the subanalyses of the 439 participants with chronic pain, the levels of pain intensity, disability, depression, and anxiety were significantly increased and the degree of life satisfaction was decreased with elevating alexithymia categories.
Conclusions
The findings demonstrate that, in the general population, higher levels of alexithymia are associated with a higher risk of having chronic pain. The early identification and treatment of alexithymia and negative affect may be beneficial in preventing chronic pain and reducing the clinical and economic burdens of chronic pain. Further research is needed to determine if this association is due to a causal effect of alexithymia on the prevalence and severity of chronic pain.
doi:10.1371/journal.pone.0090984
PMCID: PMC3951296  PMID: 24621785
13.  Delayed ejaculation and alexithymia: what is the relationship? 
F1000Research  2013;2:81.
Delayed Ejaculation (DE) is probably the least studied and understood of the male sexual dysfunctions (MSD). There is still little unanimity concerning its psychological/interpersonal aetiology. Previous studies found that MSD are strongly related with alexithymia, a multifaceted personality construct that describes a disturbance in the regulation of emotions.The aim of this study was to investigate the presence of alexithymia in men with DE and correlate alexithymia levels with DE severity. According to specific features of the symptoms, we hypothesized that alexithymia would not be correlated with this specific sexual disorder.
54 outpatients with a diagnosis of DE assessed at the Institute of Clinical Sexology and the Urology Department of Sapienza, University in Rome were enrolled in the study. DE was diagnosed after a specialist examination and according to Diagnostic and Statistical Manual of Mental Disorders -IV-TR criteria. Participants were provided with the Toronto Alexithymia Scale (20 items; TAS-20), a self-measure of the Intravaginal Ejaculation Latency Time and an ad hoc questionnaire to collect anamnestic data.
9.3% of patients could be categorized as alexithymics, 9.3% of them as borderline, while 81.4% of the sample was found to be non-alexithymic. The overall average TAS-20 score was 45.46. Results show that alexithymia is correlated neither with the presence of DE nor with its severity, in contrast to other MSDs, where this condition was found in about 30% of patients.
The data presented suggest that DE, although not correlated to alexithymia, is probably related to other psychogenic features such as hypercontrol configuration. This paper can contribute to the understanding of DE, by excluding one of the possible etiological factors, previously found to be important in the onset and the maintenance of the other MSDs. More studies are needed in order to better understand DE and provide recommendations about treatment.
doi:10.12688/f1000research.2-81.v1
PMCID: PMC3917660  PMID: 24627775
14.  Delayed ejaculation and alexithymia: what is the relationship? 
F1000Research  2013;2:81.
Delayed Ejaculation (DE) is probably the least studied and understood of the male sexual dysfunctions (MSD). There is still little unanimity concerning its psychological/interpersonal aetiology. Previous studies found that MSD are strongly related with alexithymia, a multifaceted personality construct that describes a disturbance in the regulation of emotions.The aim of this study was to investigate the presence of alexithymia in men with DE and correlate alexithymia levels with DE severity. According to specific features of the symptoms, we hypothesized that alexithymia would not be correlated with this specific sexual disorder.
54 outpatients with a diagnosis of DE assessed at the Institute of Clinical Sexology and the Urology Department of Sapienza, University in Rome were enrolled in the study. DE was diagnosed after a specialist examination and according to Diagnostic and Statistical Manual of Mental Disorders -IV-TR criteria. Participants were provided with the Toronto Alexithymia Scale (20 items; TAS-20), a self-measure of the Intravaginal Ejaculation Latency Time and an ad hoc questionnaire to collect anamnestic data.
9.3% of patients could be categorized as alexithymics, 9.3% of them as borderline, while 81.4% of the sample was found to be non-alexithymic. The overall average TAS-20 score was 45.46. Results show that alexithymia is correlated neither with the presence of DE nor with its severity, in contrast to other MSDs, where this condition was found in about 30% of patients.
The data presented suggest that DE, although not correlated to alexithymia, is probably related to other psychogenic features such as hypercontrol configuration. This paper can contribute to the understanding of DE, by excluding one of the possible etiological factors, previously found to be important in the onset and the maintenance of the other MSDs. More studies are needed in order to better understand DE and provide recommendations about treatment.
doi:10.12688/f1000research.2-81.v2
PMCID: PMC3917660  PMID: 24627775
Delayed ejaculation, alexithymia, TAS
15.  Aging and Alexithymia Association with Reduced Right Rostral Cingulate Volume 
Objectives
Previous studies have linked alexithymia to an inability to process emotions appropriately. Older persons show changes in emotion processing and have higher alexithymia scores. Because the anterior cingulate cortex (ACC) is one of the regions showing earlier decline in late-life and alexithymia appears to be related to a dysfunction in right hemisphere regions including the ACC subserving affective processes, the present study sought to test the hypothesis that reduced ACC volume accounts for the association between older age and alexithymia.
Design
Correlation analyses between functionally distinct ACC subregions, age and alexithymia features.
Setting
University of Iowa
Participants
24 healthy volunteers aged twenty-four to seventy-nine years.
Measurements
Psychiatric and neuropsychological assessment and assessment of alexithymia using the twenty items Toronto Alexithymia Scale. High-resolution magnetic resonance imaging, and in-house developed methods for ACC parcellation.
Results
Older age directly correlated with higher overall alexithymia, and reduced bilateral rostral and right dorsal ACC grey matter volume. Furthermore, higher alexithymia scores correlated with reduced right rostral ACC volume. This correlation appeared to be influenced primarily by factor 3 of the alexithymia scale measuring diversion of attention to external details in place of internal feelings.
Conclusions
These results suggest that alexithymia in older age may be a result of structural changes in the right rostral ACC.
doi:10.1097/JGP.0b013e31817e73b0
PMCID: PMC2925448  PMID: 18697882
ACC; Alexithymia; Aging; Depression; Emotion
16.  Alexithymia and the labeling of facial emotions: response slowing and increased motor and somatosensory processing 
BMC Neuroscience  2014;15:40.
Background
Alexithymia is a personality trait that is characterized by difficulties in identifying and describing feelings. Previous studies have shown that alexithymia is related to problems in recognizing others’ emotional facial expressions when these are presented with temporal constraints. These problems can be less severe when the expressions are visible for a relatively long time. Because the neural correlates of these recognition deficits are still relatively unexplored, we investigated the labeling of facial emotions and brain responses to facial emotions as a function of alexithymia.
Results
Forty-eight healthy participants had to label the emotional expression (angry, fearful, happy, or neutral) of faces presented for 1 or 3 seconds in a forced-choice format while undergoing functional magnetic resonance imaging. The participants’ level of alexithymia was assessed using self-report and interview. In light of the previous findings, we focused our analysis on the alexithymia component of difficulties in describing feelings. Difficulties describing feelings, as assessed by the interview, were associated with increased reaction times for negative (i.e., angry and fearful) faces, but not with labeling accuracy. Moreover, individuals with higher alexithymia showed increased brain activation in the somatosensory cortex and supplementary motor area (SMA) in response to angry and fearful faces. These cortical areas are known to be involved in the simulation of the bodily (motor and somatosensory) components of facial emotions.
Conclusion
The present data indicate that alexithymic individuals may use information related to bodily actions rather than affective states to understand the facial expressions of other persons.
doi:10.1186/1471-2202-15-40
PMCID: PMC4003818  PMID: 24629094
Alexithymia; Supplementary motor area; Somatosensory cortex; Facial emotion; Labeling; Toronto structured interview for Alexithymia
17.  Alexithymia and stress-induced brain activation in cocaine-dependent men and women 
Objective
Alexithymia means a reduced capacity to identify and describe one's own feelings. Both stress and an alexithymic response to stress can contribute to relapse into drug abuse, but to our knowledge the neural processing of an alexithymic response to stress in cocaine-dependent individuals has not been examined.
Methods
In a functional magnetic resonance imaging session,17 male and 10 female abstinent cocaine-dependent subjects participated in script-guided imagery of neutral or stressful situations. Spatial preprocessing and statistical analysis of brain images were performed using Statistical Parametric Mapping Software (SPM2). Blood oxygen level–dependent contrasts between stress and neutral imagery were correlated voxelwise with scores on the 26-item Toronto Alexithymia Scale (TAS).
Results
Male cocaine users demonstrated a positive correlation between TAS scores and activation in the right putamen and middle frontal cortex during stressful, compared with neutral, imagery. In contrast, no brain regions showed a negative correlation with TAS scores. Female subjects demonstrated a negative correlation between TAS scores and activation in the right amygdala, thalamus, putamen, and left frontal and bilateral temporal cortices, and no positive correlations with TAS scores during stressful, compared with neutral, imagery.
Conclusions
Women with greater alexithymic features showed reduced left-hemispheric cortical and right-hemispheric subcortical activation during processing of stress. However, men showed an opposite correlation in the right frontal cortex and putamen, suggesting that responses to stress in the putamen (activation v. deactivation) and frontal cortex (activation v. deactivation, as well as right v. left correlations) are critically different in association with alexithymia between male and female cocaine-dependent patients.
PMCID: PMC1413961  PMID: 16575427
affective symptoms; alexithymia; cocaine-related disorders; substance-related disorders
18.  Default Mode Network alterations in alexithymia: an EEG power spectra and connectivity study 
Scientific Reports  2016;6:36653.
Recent neuroimaging studies have shown that alexithymia is characterized by functional alterations in different brain areas [e.g., posterior cingulate cortex (PCC)], during emotional/social tasks. However, only few data are available about alexithymic cortical networking features during resting state (RS). We have investigated the modifications of electroencephalographic (EEG) power spectra and EEG functional connectivity in the default mode network (DMN) in subjects with alexithymia. Eighteen subjects with alexithymia and eighteen subjects without alexithymia matched for age and gender were enrolled. EEG was recorded during 5 min of RS. EEG analyses were conducted by means of the exact Low Resolution Electric Tomography software (eLORETA). Compared to controls, alexithymic subjects showed a decrease of alpha power in the right PCC. In the connectivity analysis, compared to controls, alexithymic subjects showed a decrease of alpha connectivity between: (i) right anterior cingulate cortex and right PCC, (ii) right frontal lobe and right PCC, and (iii) right parietal lobe and right temporal lobe. Finally, mediation models showed that the association between alexithymia and EEG connectivity values was directed and was not mediated by psychopathology severity. Taken together, our results could reflect the neurophysiological substrate of some core features of alexithymia, such as the impairment in emotional awareness.
doi:10.1038/srep36653
PMCID: PMC5109184  PMID: 27845326
19.  Alexithymic characteristics in pediatric patients with primary headache: a comparison between migraine and tension-type headache 
Background
Alexithymia is a personality construct characterized by difficulties in verbal emotional expression and a limited ability to use one’s imagination. Evidence of alexithymic characteristics was found in adults suffering from headache, while little is known about children. The aim of this study was to establish the prevalence of alexithymia in two different subgroups of children and adolescents suffering from primary headache. We also looked for correlation between alexithymia in children and in their mothers.
Methods
This study involved 89 participants: 47 (11 males, 36 females, aged 8 to 17 years) suffering from tension-type headache (TTH), and 42 (18 males, 24 females, aged 8 to 17 years) suffering from migraine (M), based on the International Classification of Headache Disorders (ICHD 2013). A control group of 32 headache-free subjects (26 females and 6 males, aged 8 to17 years) was also considered. Two questionnaires were administered to measure alexithymia: the Alexithymia Questionnaire for Children to young patients and controls, and the Toronto Alexithymia Scale (TAS-20) to the mothers.
Results
Higher rates of alexithymia emerged in the TTH group compared to the M group. In particular, TTH sufferers had difficulty identifying their feelings. The mothers of children with headaches didn’t score higher in alexithymia compared to other mothers. In the M and in the control group, there was a significant correlation between the rates of alexithymia in young people and in their mothers.
Conclusions
To date no other study has investigated alexithymia in subgroups of primary headaches in developmental age. Our results suggest that patients suffering from TTH are more alexithymic than M patients. This pave the way to etiopathogenetic and clinical considerations, calling for a comprehensive and multidisciplinary approach to tackle the problem of headache.
doi:10.1186/s10194-015-0572-y
PMCID: PMC4659793  PMID: 26607363
Alexithymia; Toronto Alexithymia Scale; Alexithymia Questionnaire for Children; Tension-type headache; Migraine
20.  The Specificity of the Link Between Alexithymia, Interoception, and Imitation 
Alexithymia is a subclinical condition traditionally characterized by difficulties identifying and describing one’s own emotions. Recent formulations of alexithymia, however, suggest that the condition may result from a generalized impairment in the perception of all bodily signals (“interoception”). Interoceptive accuracy has been associated with a variety of deficits in social cognition, but recently with an improved ability to inhibit the automatic tendency to imitate the actions of others. The current study tested the consequences for social cognition of the hypothesized association between alexithymia and impaired interoception by examining the relationship between alexithymia and the ability to inhibit imitation. If alexithymia is best characterized as a general interoceptive impairment, then one would predict that alexithymia would have the same relationship with the ability to control imitation as does interoceptive accuracy. Forty-three healthy adults completed measures of alexithymia, imitation-inhibition, and as a control, inhibition of nonimitative spatial compatibility. Results revealed the predicted relationship, such that increasing alexithymia was associated with an improved ability to inhibit imitation, and that this relationship was specific to imitation-inhibition. These results support the characterization of alexithymia as a general interoceptive impairment and shed light on the social ability of alexithymic individuals—with implications for the multitude of psychiatric, neurological, and neurodevelopmental disorders associated with high rates of alexithymia.
doi:10.1037/xhp0000310
PMCID: PMC5082312  PMID: 27786535
alexithymia; interoception; imitation-inhibition; self–other processing
21.  Parental bonding and personality characteristics of first episode intention to suicide or deliberate self-harm without a history of mental disorders 
BMC Public Health  2013;13:421.
Background
There is substantial overlap between deliberate self-harm (DSH) and intention to suicide (ITS), although the psychopathologies and motivations behind these behaviors are distinctly different. The purpose of this study was to investigate (i) the pathway relationship among parental bonding, personality characteristics, and alexithymic traits, and (ii) the association of these features with ITS and DSH using structural equation modeling to determine the risks and protective factors for these behaviors.
Methods
Sixty-nine first-time DSH and 36 first-time ITS patients without medical or psychiatric illnesses, and 66 controls were recruited. The Parental Bonding Inventory (PBI), Eysenck Personality Questionnaire (EPQ), 20-item Toronto Alexithymia Scale (TAS-20), and the Chinese Health Questionnaire (CHQ) were filled out by the participants.
Results
Our structural equation models showed that parental bonding had the greatest influence on the development of DSH behavior in patients. On the other hand, participants who were younger, less extraverted, with a greater extent of the alexithymic trait of difficulty identifying feeling (DIF), and a worse mental health condition, were more likely to develop ITS behavior. Males were more likely than females to develop the alexithymic trait of DIF.
Conclusions
Although there are many covariates that affect both ITS and DSH behaviors, these covariates may have different functions in the development of these behaviors, thus revealing the psychopathological difference between DSH and ITS. Policymakers should consider these differences and build intervention and prevention programs for gender- and age-specific high-risk groups to target the differences, with a focus on family counseling to treat DSH and a focus on attempting to increase emotional awareness to treat ITS.
doi:10.1186/1471-2458-13-421
PMCID: PMC3654887  PMID: 23635081
Intention to suicide; Deliberate self-harm; Community; Parental bonding; Alexithymic trait; Structural equation modeling
22.  Alexithymia, anger and psychological distress in patients with myofascial pain: a case-control study 
Aims: The aim of this study was to investigate psychological distress, anger and alexithymia in a group of patients affected by myofascial pain (MP) in the facial region.
Methods: 45 MP patients [mean (SD) age: 38.9 (11.6)] and 45 female healthy controls [mean (SD) age: 37.8 (13.7)] were assessed medically and psychologically. The medically evaluation consisted of muscle palpation of the pericranial and cervical muscles. The psychological evaluation included the assessment of depression (Beck Depression Inventory—short form), anxiety [State-Trait Anxiety Inventory Form Y (STAI-Y)], emotional distress [Distress Thermometer (DT)], anger [State-Trait Anger Expression Inventory—2 (STAXI-2)], and alexithymia [Toronto Alexithymia Scale (TAS)].
Results: the MP patients showed significantly higher scores in the depression, anxiety and emotional distress inventories. With regard to anger, only the Anger Expression-In scale showed a significant difference between the groups, with higher scores for the MP patients. In addition, the MP patients showed significantly higher alexithymic scores, in particular in the Difficulty in identifying feelings (F1) subscale of the TAS-20. Alexithymia was positively correlated with the Anger Expression-In scale. Both anger and alexithymia showed significant positive correlations with anxiety scores, but only anger was positively correlated with depression.
Conclusion: A higher prevalence of depressive and anxiety symptoms associated with a higher prevalence of alexithymia and expression-in modality to cope with anger was found in the MP patients. Because the presence of such psychological aspects could contribute to generate or exacerbate the suffering of these patients, our results highlight the need to include accurate investigation of psychological aspects in MP patients in normal clinical practice in order to allow clinicians to carry out more efficacious management and treatment strategies.
doi:10.3389/fpsyg.2013.00490
PMCID: PMC3728491  PMID: 23914181
myofascial facial pain; anxiety; depression; anger; alexithymia
23.  The relationships between interoception and alexithymic trait. The Self-Awareness Questionnaire in healthy subjects 
Frontiers in Psychology  2015;6:1149.
Interoception is the basic process enabling evaluation of one's own bodily states. Several previous studies suggested that altered interoception might be related to disorders in the ability to perceive and express emotions, i.e., alexithymia, and to defects in perceiving and describing one's own health status, i.e., hypochondriasis. The main aim of the present study was to investigate the relationships between alexithymic trait and interoceptive abilities evaluated by the “Self-Awareness Questionnaire” (SAQ), a novel self-report tool for assessing interoceptive awareness. Two hundred and fifty healthy subjects completed the SAQ, the Toronto Alexithymia Scale-20 items (TAS-20), and a questionnaire to assess hypochondriasis, the Illness Attitude Scale (IAS). The SAQ showed a two-factor structure, with good internal consistency (Cronbach's alpha = 0.88). We observed significant direct correlations between SAQ, TAS-20 and two of its subscales, and the IAS. Regression analysis confirmed that the difficulty in identifying and expressing emotions is significantly related with awareness for one's own interoceptive feelings and with a tendency to misinterpret and amplify bodily sensations. From a clinical point of view, the assessment of interoceptive awareness by the SAQ could be pivotal in evaluating several psychopathological conditions, such as the somatoform disorders.
doi:10.3389/fpsyg.2015.01149
PMCID: PMC4528101  PMID: 26300829
interoceptive awareness; emotion; alexithymia; hypochondriasis; health; insular cortex
24.  The Assessment of Alexithymia in Medical Settings: Implications for Understanding and Treating Health Problems 
Journal of personality assessment  2007;89(3):230-246.
The construct of alexithymia encompasses the characteristics of difficulty identifying feelings, difficulty describing feelings, externally oriented thinking, and a limited imaginal capacity. These characteristics are thought to reflect deficits in the cognitive processing and regulation of emotions and to contribute to the onset or maintenance of several medical and psychiatric disorders. This article reviews recent methods for assessing alexithymia and examines how assessing alexithymia can inform clinical practice. Alexithymia is associated with heightened physiological arousal, the tendency to notice and report physical symptoms, and unhealthy compulsive behaviors. Alexithymic patients may respond poorly to psychological treatments, although perhaps not to cognitive-behavioral techniques, and it is unclear whether alexithymia can be improved through treatment. Interpretive problems regarding alexithymia include its overlap with other traits, whether it is secondary to illness or trauma, the possibility of subtypes, and low correlations among multiple measures. Nonetheless, we encourage the assessment of alexithymia in applied settings.
doi:10.1080/00223890701629698
PMCID: PMC2931418  PMID: 18001224
25.  Abnormalities in Automatic Processing of Illness-Related Stimuli in Self-Rated Alexithymia 
PLoS ONE  2015;10(6):e0129905.
Aim
To investigate abnormalities in automatic information processing related to self- and observer-rated alexithymia, especially with regard to somatization, controlling for confounding variables such as depression and affect.
Sample
89 healthy subjects (60% female), aged 19–71 years (M = 32.1). 58 subjects were additionally rated by an observer.
Measures
Alexithymia (self-rating: TAS-20, observer rating: OAS); automatic information processing (priming task including verbal [illness-related, negative, positive, neutral] and facial [negative, positive, neutral] stimuli); somatoform symptoms (SOMS-7T); confounders: depression (BDI), affect (PANAS).
Results
Higher self-reported alexithymia scores were associated with lower reaction times for negative (r = .19, p < .10) and positive (r = .26, p < .05) verbal primes when the target was illness-related. Self-reported alexithymia was correlated with number (r = .42, p < .01) and intensity of current somatoform symptoms (r = .36, p < .01), but unrelated to observer-rated alexithymia (r = .11, p = .42).
Discussion
Results indicate a faster allocation of attentional resources away from task-irrelevant information towards illness-related stimuli in alexithymia. Considering the close relationship between alexithymia and somatization, these findings are compatible with the theoretical view that alexithymics focus strongly on bodily sensations of emotional arousal. A single observer rating (OAS) does not seem to be an adequate alexithymia-measure in community samples.
doi:10.1371/journal.pone.0129905
PMCID: PMC4474975  PMID: 26090893

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