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1.  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
2.  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
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.  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
5.  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
6.  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
7.  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
8.  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
9.  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
10.  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
11.  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
12.  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
13.  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
14.  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
15.  The Relationship between Alexithymia and General Symptoms of Patients with Depressive Disorders 
Psychiatry Investigation  2008;5(3):179-185.
Objective
Depression has been associated with alexithymic features. However, few studies have investigated the differences in the general symptoms of patients with depressive disorders according to the presence of alexithymia. Thus, the aim of this study was to evaluate the relationship between alexithymia and symptoms experienced by patients with clinically diagnosed depressive disorders.
Methods
A chart review of patients who were evaluated using the Korean version of the 20-item Toronto Alexithymia Scale (TAS-20) and Symptom Checklist 90-Revised (SCL-90-R) at the same time between the years 2003 and 2007 was conducted. A total of 104 patients with depressive disorders were included and divided into two groups: alexithymia (n=52) and non-alexithymia (n=52). A direct comparison between the two groups was carried out. Regression analysis was also carried out for the TAS-20 total and subset scores in order to model the relationship between alexithymia and symptoms.
Results
The presence of alexithymia was confirmed in 50% of the patients with depressive disorders, and the symptoms of depressive patients with alexithymia were more severe than those of their non-alexithymic counterparts on all 9 symptom domains of the SCL-90-R. Furthermore, regression analysis revealed that the presence of alexithymia was positively associated with depression, phobic anxiety, and psychoticism but inversely associated with anxiety.
Conclusion
These results suggest that the clinical features of depression are partially dependent on the presence of alexithymia. Alexithymic patients with depressive disorders are likely to show more severe depressive, psychotic, and phobic symptoms. In other words, clinicians should suspect the presence of alexithymic tendencies if these symptoms coexist in patients with depressive disorders and address their difficulties in effective communication.
doi:10.4306/pi.2008.5.3.179
PMCID: PMC2796028  PMID: 20046363
Alexithymia; Depression; Symptomatology; Toronto Alexithymia Scale-20; Symptom Checklist-90-Revised
16.  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
17.  Empathic brain responses in insula are modulated by levels of alexithymia but not autism 
Brain  2010;133(5):1515-1525.
Difficulties in social cognition are well recognized in individuals with autism spectrum conditions (henceforth ‘autism’). Here we focus on one crucial aspect of social cognition: the ability to empathize with the feelings of another. In contrast to theory of mind, a capacity that has often been observed to be impaired in individuals with autism, much less is known about the capacity of individuals with autism for affect sharing. Based on previous data suggesting that empathy deficits in autism are a function of interoceptive deficits related to alexithymia, we aimed to investigate empathic brain responses in autistic and control participants with high and low degrees of alexithymia. Using functional magnetic resonance imaging, we measured empathic brain responses with an ‘empathy for pain’ paradigm assessing empathic brain responses in a real-life social setting that does not rely on attention to, or recognition of, facial affect cues. Confirming previous findings, empathic brain responses to the suffering of others were associated with increased activation in left anterior insula and the strength of this signal was predictive of the degree of alexithymia in both autistic and control groups but did not vary as a function of group. Importantly, there was no difference in the degree of empathy between autistic and control groups after accounting for alexithymia. These findings suggest that empathy deficits observed in autism may be due to the large comorbidity between alexithymic traits and autism, rather than representing a necessary feature of the social impairments in autism.
doi:10.1093/brain/awq060
PMCID: PMC2859151  PMID: 20371509
empathy; autism; alexithymia; interoception; anterior insula; mentalizing; theory of mind
18.  Alexithymia, emotion processing and social anxiety in adults with ADHD 
Objective
Given sparse research on the issue, this study sought to shed light upon the interactions of alexithymia, emotion processing, and social anxiety in adults with attention-deficit hyperactivity disorder (ADHD).
Subjects and methods
73 German adults with ADHD according to DSM-IV diagnostic criteria participated. We used the Toronto Alexithymia Scale (TAS-20) to assess alexithymia, the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS) to assess different features of social anxiety, and we applied the German 'Experience of Emotions Scale' (SEE) to measure emotion processing.
Results
40% of the sample were found to meet the DSM-IV criteria of social anxiety disorder, and about 22% were highly alexithymic according to a TAS-20 total score ≥ 61; however, the mean TAS-20 total score of 50.94 ± 9.3 was not much higher than in community samples. Alexithymic traits emerged to be closely linked to emotion processing problems, particularly 'difficulty accepting own emotions', and to social anxiety features.
Discussion/conclusion
Our findings suggest interactions of alexithymia, emotion processing dysfunction, and social anxiety in adults with ADHD, which may entail the therapeutic implication to thoroughly instruct these patients to identify, accept, communicate, and regulate their emotions to aid reducing interaction anxiety.
doi:10.1186/2047-783X-15-9-403
PMCID: PMC3351908  PMID: 20952350
Attention deficit/hyperactivity disorder; adults; TAS-20; SPS; SIAS; social phobia
19.  Alexithymia and Aging 
Consistent with the emotional changes associated with later life, higher alexithymia scores are widely reported in older adults, but their significance has not been fully examined. We posited that association between alexithymia and poorer neurocognition would support the deficit nature of alexithymia in later life. Widely used neurocognitive tests assessing the relative integrity of the left and right hemisphere functions were used to examine the extent to which alexithymia of older age is associated with poor left or right hemisphere functioning. Healthy community-dwelling volunteers (20 young and 20 elderly subjects) were studied with the 20-item Toronto Alexithymia Scale. Neurocognitive competence was assessed using a neuropsychological battery measuring attention, language, memory, visuospatial abilities, and executive functions. Neurocognitive abilities were strongly age-related and indirectly correlated with alexithymia. Alexithymia total score appeared to be uniquely predicted by Raven Matrices and Rey’s Figure Recall. These results support the deficit hypothesis alexithymia of older age.
doi:10.1097/NMD.0b013e3181fe743e
PMCID: PMC3789519  PMID: 21135641
Aging; alexithymia; neuropsychology; Raven Colored Progressive Matrices; Rey’s Complex Figure; story recall; memory
20.  Alexithymia in juvenile primary headache sufferers: a pilot study 
Starting in the 1990s, there has been accumulating evidence of alexithymic characteristics in adult patients with primary headache. Little research has been conducted, however, on the relationship between alexithymia and primary headache in developmental age. In their research on alexithymia in the formative years, the authors identified one of the most promising prospects for research, as discussed here. The aim of this study was to verify whether there is: (a) a link between tension-type headache and alexithymia in childhood and early adolescence; and (b) a correlation between alexithymia in children/preadolescents and their mothers. This study was based on an experimental group of 32 patients (26 females and 6 males, aged from 8 to 15 years, mean 11.2 ± 2.0) suffering from tension-type headache and 32 control subjects (26 females and 6 males, aged from 8 to 15 years, mean 11.8 ± 1.6). Tension-type headache was diagnosed by applying the International Headache Classification (ICHD-II, 2004). The alexithymic construct was measured using an Italian version of the Alexithymia Questionnaire for Children in the case of the juvenile patients and the Toronto Alexithymia Scale (TAS-20) for their mothers. Higher rates of alexithymia were observed in the children/preadolescents in the experimental group (EG) than in the control group; in the EG there was no significant correlation between the alexithymia rates in the children/preadolescents and in their mothers.
doi:10.1007/s10194-010-0248-6
PMCID: PMC3072508  PMID: 20730593
Alexithymia; Toronto alexithymia scale; Primary headache; Tension-type headache; Children and adolescents
21.  Alexithymia and Stress Response Patterns among Patients with Depressive Disorders in Korea 
Psychiatry Investigation  2009;6(1):13-18.
Objective
Alexithymic characteristics may represent cognitive and affective mediators between stressors and stress responses among those with depressive disorders. This study evaluated how alexithymic characteristics, as measured by the Korean version of the Toronto Alexithymia Scale-20 (TAS-20K), could be related to stress response patterns, as measured by the Stress Response Inventory (SRI), within a sample composed of individuals diagnosed with depressive disorders.
Methods
Participants comprised a cross section of patients diagnosed with depressive disorders (n=98). Data on demographic and psychosocial factors (i.e., sex, age, and level of education), clinical profiles {i.e., primary and comorbid psychiatric conditions meeting the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria at the time of the evaluation}, duration of illness, medications, and Clinical Global Impression (CGI) scores, and the results of psychological assessments (TAS-20K, SRI) were analyzed.
Results
Patients having depressive disorders with alexithymia obtained significantly higher scores in terms of all seven subscales of the SRI, as compared to those without alexithymia, a logistic regression model was used to assess possible predictors for the presence of alexithymia in patients with depressive disorders, including the seven subscales of the SRI, gender, age, and duration of illness. We found that aggressive and somatizing responses to stress were significantly associated with the presence of alexithymia among patients with depression.
Conclusion
These findings suggest that patients having depression with alexithymia were more susceptible to stress than those without alexithymia. Clinicians might improve their treatment of depression by identifying the clinical predictors for alexithymia and by helping those individuals demonstrating such symptoms in coping with emotionally stressful situations.
doi:10.4306/pi.2009.6.1.13
PMCID: PMC2796034  PMID: 20046368
Alexithymia; Depression; Stress
22.  Migraine prevalence, alexithymia, and post-traumatic stress disorder among medical students in Turkey 
The Journal of Headache and Pain  2012;13(6):459-467.
The aim of this study was to investigate the prevalence of migraine, alexithymia, and post-traumatic stress disorder among medical students at Cumhuriyet University of Sivas in Turkey. A total of 250 medical students participated in this study and answered the questionnaires. The study was conducted in three stages: the self-questionnaire, the neurological evaluation, and the psychiatric evaluation. In the first stage, the subjects completed a questionnaire to assess migraine symptoms and completed the three-item Identification of Migraine Questionnaire, the Toronto Alexithymia Scale, and the Post-Traumatic Stress Disorder Checklist-Civilian Version Scale. The subjects who reported having a migraine underwent a detailed neurological evaluation conducted by a neurologist to confirm the diagnosis. In the final stage, the subjects with a migraine completed a psychiatric examination using the structured clinical interview for DSM-IV-R Axis I. The actual prevalence of migraine among these medical students was 12.6 %. The students with a migraine were diagnosed with alexithymia and post-traumatic stress disorder more frequently than those without migraine. The Migraine Disability Assessment Scale scores correlated with the post-traumatic stress disorder scores. The results of this study indicate that migraine was highly prevalent among medical students in Turkey and was associated with the alexithymic personality trait and comorbid psychiatric disorders including post-traumatic stress disorder. Treatment strategies must be developed to manage these comorbidities.
doi:10.1007/s10194-012-0452-7
PMCID: PMC3464464  PMID: 22535148
Prevalence; Migraine; Post-traumatic stress disorder; Alexithymia; Comorbidity; Medical students
23.  Alexithymia may modulate decision making in patients with de novo Parkinson’s disease  
Functional Neurology  2011;26(3): 127 - 131 .
Summary
The aim of this study was to investigate whether and how alexithymia may influence decision making under conditions of uncertainty, assessed using the Iowa Gambling Task, in patients with newly diagnosed, untreated (de novo) Parkinson’s disease, as previously reported for healthy subjects.
Twenty-four patients with de novo Parkinson’s disease underwent a neuropsychological and neuropsychiatric assessment, including the Toronto Alexithymia Scale, the Geriatric Depression Scale Short Form, and the Iowa Gambling Task (IGT).
The assessment showed that 12 patients were alexithymic and 12 were non-alexithymic; seven patients were found to be mildly depressed and 17 non-depressed. Alexithymic and non-alexithymic patients did not differ in the IGT total score; however, significant differences emerged across the third block of the IGT, in which the alexithymic patients outperformed the nonalexithymic patients. Depression did not influence IGT performance.
Alexithymia may modulate decision making, as assessed with the IGT; alexithymia could be associated with faster learning to avoid risky choices and negative feedback, as previously reported in some studies conducted in anxious or depressed patients.
PMCID: PMC3814549  PMID: 22152433
alexithymia ;  anxiety ;  decision making ;  de novo Parkinson’s disease ;  depression ;  Iowa Gambling Task
24.  Interoceptive–reflective regions differentiate alexithymia traits in depersonalization disorder 
Psychiatry Research  2013;214(1):66-72.
It is unclear to what degree depersonalization disorder (DPD) and alexithymia share abnormal brain mechanisms of emotional dysregulation. We compared cerebral processing of facial expressions of emotion in individuals with DPD to normal controls (NC). We presented happy and sad emotion expressions in increasing intensities from neutral (0%) through mild (50%) to intense (100%) to DPD and non-referred NC subjects in an implicit event-related fMRI design, and correlated respective brain activations with responses on the 20-item Toronto Alexithymia Scale (TAS-20) and its three subscales F1-F3. The TAS-20 predicts clinical diagnosis of DPD with a unique variance proportion of 38%. Differential regression analysis was utilized to ascertain brain regions for each alexithymia subscale. Differential regions of total alexithymia severity for happy emotion were the globus pallidus externus; for identifying feelings (TAS-20 F1 subscale), the right anterior insula; for description of feelings (F2), the right dorsal mid-anterior cingulate gyrus (BA 24); and for externally oriented cognitive style (F3), the left paracingulate gyrus (BA 32). For sad emotion, the differential region for the total TAS-20 score was the dorsal anterior cingulate gyrus (BA 24); for TAS-20 F1, the left inferior anterior insula; for TAS-20 F2, the right PCC (BA 31); and for TAS-20 F3, the right orbital gyrus (BA 10). Supporting our hypotheses, the ascertained brain regions for TAS-20 subscales subserve interoception, monitoring and reflection of internal states and emotion. The presented analyses provide evidence that alexithymia plays a substantial role in emotional dysregulation in DPD, presumably based on restrictions in interoception.
doi:10.1016/j.pscychresns.2013.05.006
PMCID: PMC4024664  PMID: 23932225
Depersonalization Disorder; Functional magnetic resonance imaging; Facial expressions; Differential regression analysis; Toronto Alexithymia Scale; Functional connectivity
25.  A Comparative Study on Alexithymia in Depressive, Somatoform, Anxiety, and Psychotic Disorders among Koreans 
Psychiatry Investigation  2012;9(4):325-331.
Objective
Little is known about the characteristic differences in alexithymic construct in various psychiatric disorders because of a paucity of direct comparisons between psychiatric disorders. Therefore, this study explored disorder-related differences in alexithymic characteristics among Korean patients diagnosed with four major psychiatric disorders (n=388).
Methods
Alexithymic tendencies, as measured by the Korean version of the 20-item Toronto Alexithymia Scale (TAS-20K), of patients classified into four groups according to major psychiatric diagnosis were compared. The groups consisted of patients with depressive disorders (DP; n=125), somatoform disorders (SM; n=78), anxiety disorders (AX; n=117), and psychotic disorders (PS; n=68).
Results
We found that substantial portions of patients in all groups were classified as having alexithymia and no statistical intergroup differences emerged (42.4%, 35.9%, 35.3%, and 33.3% for DP, SM, PS, and AX). However, patients with DP obtained higher scores in factor 2 (difficulties describing feelings) than those with SM or AX, after adjusting for demographic variables.
Conclusion
These findings suggest that alexithymia might be associated with a higher vulnerability to depressive disorders and factor 2 of TAS-20K could be a discriminating feature of depressive disorders.
doi:10.4306/pi.2012.9.4.325
PMCID: PMC3521107  PMID: 23251195
Alexithymia; Depressive disorder; Somatoform disorder; Anxiety disorder; Psychotic disorder

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