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1.  Relationship between alexithymia and coping strategies in patients with somatoform disorder 
Purpose
A multidimensional intervention integrating alexithymia, negative affect, and type of coping strategy is needed for the effective treatment of somatoform disorder; however, few studies have applied this approach to the three different dimensions of alexithymia in patients with somatoform disorder. The purpose of this study was to determine the relationship between type of coping strategy and three different dimensions of alexithymia expressed in patients.
Patients and methods
A total of 196 patients with somatoform disorder completed the 20-item Toronto Alexithymia Scale, the Zung Self-Rating Depression Scale, the Spielberger State–Trait Anxiety Inventory, the Somatosensory Amplification Scale, and the Lazarus Stress Coping Inventory. The relationships between alexithymia (Toronto Alexithymia Scale – 20 score and subscales), demographic variables, and psychological inventory scores were analyzed using Pearson’s correlation coefficients and stepwise multiple regression analysis.
Results
The mean Toronto Alexithymia Scale – 20 total score (56.1±10.57) was positively correlated with the number of physical symptoms as well as with psychopathology scores (Self-Rating Depression Scale, State–Trait Anxiety Inventory trait, state, and Somatosensory Amplification Scale), but negatively correlated with planful problem solving, confrontive coping, seeking social support, and positive reappraisal coping scores. With respect to coping strategy, multiple regression analyses revealed that “difficulty in identifying feelings” was positively associated with an escape–avoidance strategy, “difficulty in describing feelings” was negatively associated with a seeking social support strategy, and “externally oriented thinking” was negatively associated with a confrontive coping strategy.
Conclusion
Alexithymia was strongly associated with the number of somatic symptoms and negative affect. Patients with high “difficulty in describing feelings” tend to rely less on seeking social support, and patients with high “externally oriented thinking” tend to rely less on confrontive coping strategies. The coping skills intervention implemented should differ across individuals and should be based on the alexithymia dimension of each patient.
doi:10.2147/NDT.S55956
PMCID: PMC3883553  PMID: 24403835
somatoform disorder; alexithymia; stress; coping strategies
2.  Traumatic experiences, alexithymia, and posttraumatic symptomatology: a cross-sectional population-based study in Germany 
European Journal of Psychotraumatology  2014;5:10.3402/ejpt.v5.23870.
Objective
Previous studies have established an association between number of traumatic experiences and alexithymia. The present study examines this relationship in a large-scale representative sample of the German general population (N=2,507) and explores the potential mediating effects of posttraumatic symptomatology, particularly avoidance/numbing.
Methods
Alexithymia was assessed with the German version of the Toronto Alexithymia Scale (TAS-20). Posttraumatic symptomatology was operationalized by the symptom score of the modified German version of the Posttraumatic Symptom Scale, and traumatic experiences were assessed with the trauma list of the Munich Composite International Diagnostic Interview. Two mediation analyses were conducted.
Results
Of the total sample, 24.2% (n=606) reported at least one traumatic experience, 10.6% (n=258) were classified as alexithymic, and 2.4% (n=59) fulfilled the criteria of posttraumatic stress disorder (PTSD). Participants who had survived five or more traumatic experiences had significantly higher alexithymia sum scores. The PTSD symptom cluster avoidance/numbing mediated the association between the number of traumatic experiences and alexithymia.
Conclusions
Our findings illustrate an association between number of traumatic experiences and alexithymia and the influence of emotional avoidance and numbing within this relationship. The significant relationship between alexithymia and number of traumatic experiences in a general population sample further supports the concept of multiple and complex traumatization as associated with alexithymia. The results suggest the importance of further investigations determining the causal impact of alexithymia both as a potential premorbid trait and as consequence of traumatization. Lastly, future investigations are needed to clarify alexithymia as a distinct trauma-relevant characteristic for better diagnostics and specialized trauma-integrative therapy.
doi:10.3402/ejpt.v5.23870
PMCID: PMC4149745  PMID: 25206956
PTSD; TAS-20; multiple and complex traumatization; avoidance/numbing; mediation
3.  Alexithymia and the Processing of Emotional Facial Expressions (EFEs): Systematic Review, Unanswered Questions and Further Perspectives 
PLoS ONE  2012;7(8):e42429.
Alexithymia is characterized by difficulties in identifying, differentiating and describing feelings. A high prevalence of alexithymia has often been observed in clinical disorders characterized by low social functioning. This review aims to assess the association between alexithymia and the ability to decode emotional facial expressions (EFEs) within clinical and healthy populations. More precisely, this review has four main objectives: (1) to assess if alexithymia is a better predictor of the ability to decode EFEs than the diagnosis of clinical disorder; (2) to assess the influence of comorbid factors (depression and anxiety disorder) on the ability to decode EFE; (3) to investigate if deficits in decoding EFEs are specific to some levels of processing or task types; (4) to investigate if the deficits are specific to particular EFEs. Twenty four studies (behavioural and neuroimaging) were identified through a computerized literature search of Psycinfo, PubMed, and Web of Science databases from 1990 to 2010. Data on methodology, clinical characteristics, and possible confounds were analyzed. The review revealed that: (1) alexithymia is associated with deficits in labelling EFEs among clinical disorders, (2) the level of depression and anxiety partially account for the decoding deficits, (3) alexithymia is associated with reduced perceptual abilities, and is likely to be associated with impaired semantic representations of emotional concepts, and (4) alexithymia is associated with neither specific EFEs nor a specific valence. These studies are discussed with respect to processes involved in the recognition of EFEs. Future directions for research on emotion perception are also discussed.
doi:10.1371/journal.pone.0042429
PMCID: PMC3426527  PMID: 22927931
4.  RELATIONSHIPS AMONG ALEXITHYMIA AND PAIN INTENSITY, PAIN INTERFERENCE, AND VITALITY IN PERSONS WITH NEUROMUSCULAR DISEASE: CONSIDERING THE EFFECT OF NEGATIVE AFFECTIVITY 
Pain  2010;149(2):273-277.
Alexithymia, the inability to identify or label emotions, has been shown to be associated with pain in patients with a number of chronic pain conditions. We sought to: (1) replicate this association in samples of persons with chronic pain secondary to neuromuscular disease; (2) extend this finding to other important pain-related measures, and (3) to determine whether relationships among alexithymia and study variables existed after controlling for negative affect. One hundred and twenty-nine individuals with muscular dystrophy and chronic pain were administered measures of alexithymia (Toronto Alexithymia Scale, TAS-20), pain intensity (0–10 NRS), pain interference (Brief Pain Inventory Interference scale), mental health (SF-36 Mental Health scale; as a proxy measure of negative affect) and vitality (SF-36 Vitality scale). Higher TAS scores were associated significantly with higher pain intensity and interference, and less vitality. Although the strengths of these associations were reduced when mental health was used as a control, the associations between the Difficulty Identifying Feelings scale and vitality, and the Externally Oriented Thinking and Total TAS scales and pain intensity remained statistically significant. The findings replicate and extend previous findings concerning the associations between alexithymia and important pain-related variables in a sample of persons with chronic pain and neuromuscular disease. Future research is needed to determine the extent to which the associations are due to (1) a possible causal effect of alexithymia on patient functioning that is mediated via its effects on negative affect or (2) the possibility that alexithymia/outcome relationships reflect response bias caused by general negative affectivity.
doi:10.1016/j.pain.2010.02.012
PMCID: PMC2860641  PMID: 20207082
Alexithymia; neuromuscular disease; chronic pain; TAS-20; SF-36
5.  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
6.  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
7.  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
8.  Alexithymia and fear of pain independently predict heat pain intensity ratings among undergraduate university students 
BACKGROUND:
Alexithymia is a disturbance in awareness and cognitive processing of affect that is associated with over-reporting of physical symptoms, including pain. The relationship between alexithymia and other psychological constructs that are often associated with pain has yet to be evaluated.
OBJECTIVES:
The present study examined the importance of alexithymia in the pain experience in relation to other integral psychological components of Turk’s diathesis-stress model of chronic pain and disability, including fear of pain, anxiety sensitivity, pain avoidance and pain catastrophizing.
METHODS:
Heat pain stimuli, using a magnitude estimation procedure, and five questionnaires (Anxiety Sensitivity Index, Fear of Pain Questionnaire III, Pain Catastrophizing Scale, avoidance subscale of the Pain Anxiety Symptoms Scale-20 and Toronto Alexithymia Scale-20) were administered to 67 undergraduate students (44 women) with a mean (± SD) age of 20.39±3.77 years.
RESULTS:
Multiple linear regression analysis revealed that sex, fear of pain and alexithymia were the only significant predictors of average heat pain intensity (F[6, 60]=5.43; R2=0.35; P=0.008), accounting for 6.8%, 20.0% and 9.6% of unique variance, respectively. Moreover, the difficulty identifying feelings and difficulty describing feelings subscales, but not the externally oriented thinking subscale of the Toronto Alexithymia Scale-20 significantly predicted average heat pain intensity.
CONCLUSIONS:
Individuals with higher levels of alexithymia or increased fear of pain reported higher average pain intensity ratings. The relationship between alexithymia and pain intensity was unrelated to other psychological constructs usually associated with pain. These findings suggest that difficulties with emotion regulation, either through reduced emotional awareness via alexithymia or heightened emotional awareness via fear of pain, may negatively impact the pain experience.
PMCID: PMC2734517  PMID: 19714270
Alexithymia; Fear of pain; Heat pain stimulation; Pain intensity; Undergraduates
9.  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
10.  Alexithymia, anxiety and depression in patients with psoriasis: a case–control study 
Background
Alexithymia, the difficulty in describing or recognizing emotions, has been associated with various psychosomatic pathologies including psoriasis. The aim of this study was to examine the prevalence of alexithymia and its association with anxiety and depression in patients with psoriasis compared with healthy participants, while taking into consideration demographic and clinical variables.
Methods
One hundred and eight psoriatic patients and 100 healthy participants from the general population completed the Toronto Alexithymia Scale (TAS-20) and the Hospital Anxiety and Depression Scale (HADS). The severity of patients’ psoriasis was clinically assessed using the Psoriasis Area and Severity Index (PASI).
Results
Psoriatic patients had higher levels of alexithymia compared with healthy participants. While a rather high rate of psoriatic patients presented anxiety and depression as defined by the HADS, the differences that were found in comparison with the control group were not significant. Neither alexithymia nor its dimensions, difficulty in identifying feelings (DIF), difficulty in describing feelings (DDF) and externally oriented thinking (EOT), were associated with gender or psoriasis severity. Age was associated only with EOT, which was independent of depression and anxiety. Higher anxiety and depression were connected with higher alexithymia and DIF, while higher anxiety with higher DDF as well.
Conclusions
The alexithymia prevalence was higher in psoriatic patients than that in healthy participants, while it was positively correlated with anxiety and depression. Difficulty in identifying feelings was connected with both anxiety and depression, whereas difficulty in describing them was only with anxiety. Finally, externally oriented thinking was predicted only from age.
doi:10.1186/s12991-014-0038-7
PMCID: PMC4269099  PMID: 25520742
Alexithymia; Anxiety; Depression; Psoriasis; TAS-20
11.  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
12.  Association of Alexithymia and Depression Symptom Severity in Adults 50 Years of Age and Older 
Objectives
Alexithymia is a characteristic style of thinking and feeling involving deficits in the recognition of emotions. It is associated with depression onset and severity in younger adults, but researchers have not yet examined the association between alexithymia and depression severity in clinically depressed older adults.
Design
Cross-sectional.
Participants
One hundred and thirty four patients 50 years and age or older with a confirmed DSM-IV Axis I mood disorder and currently receiving mental health treatment.
Measures
Alexithymia was measured using the Toronto Alexithymia Scale-20 (TAS-20), a 20-item measure with subscales assessing Difficulty Identifying Feelings (DIF), Difficulty Describing Feelings (DDF), and Externally Oriented Thinking (EOT). Depression symptom severity was measured using the Beck Depression Inventory Second Edition (BDI-II).
Results
Total alexithymia scores were independently related to depressive symptom severity after controlling for demographics, cognitive functioning and illness burden. DIF and DDF subscale scores were also independently associated with BDI-II scores.
Conclusion
The association between alexithymia and depression symptom severity could be attributed to difficulties in recognizing and describing negative emotions and resulting delays in seeking mental health treatment. Future research should focus on modifiable risk factors related to difficulties identifying and describing feelings.
doi:10.1097/JGP.0b013e3181bd1bfe
PMCID: PMC3071987  PMID: 20094018
Alexithymia; depression; older adults
13.  Prevalence of alexithymia and its association with anxiety and depression in a sample of Greek chronic obstructive pulmonary disease (COPD) outpatients 
Background
Chronic obstructive pulmonary disease (COPD) is a major health problem, especially in adults over 40 years of age, and has a great social and economic impact. The psychological morbidity of COPD patients with regard to anxiety and depressive symptoms has been extensively studied in the past. However, few studies have investigated the prevalence of alexithymia in these patients, as well as its association with this comorbidity. Based on this fact, we studied the prevalence of alexithymia and its association with anxiety and depressive symptoms in COPD outpatients.
Methods
The present study included 167, randomly selected, outpatients diagnosed with COPD. Alexithymia, anxiety and depression were assessed using the Toronto Alexithymia Scale (TAS-20), Spielberger Trait Anxiety Inventory (STAI), and Beck Depression Inventory (BDI), respectively.
Results
The mean BDI score was 12.88 (SD: 7.7), mean STAI score 41.8 (SD: 11.0) and mean TAS-20 score 48.2 (SD: 11.5). No differences were observed between genders regarding age and alexithymia (t test P > 0.05), while female patients presented higher depression and trait anxiety scores than males (t test P < 0.05). Clinically significant levels of anxiety were present in 37.1% of men, and in 45.7% of women. The mean depression score was also higher than the corresponding mean score in the general population (one-sample t test P < 0.01), while 27.7% and 30.5% of the sample presented mild and moderate to severe depression, respectively. Finally, a strong correlation was observed between alexithymia, depression and anxiety.
Conclusions
This study confirms the high prevalence of anxiety and depression symptoms in Greek outpatients with COPD. The prevalence of alexithymia in COPD patients, contrary to what has been observed in patients with other chronic respiratory diseases, seem to be lower. However, we observed a strong association between alexithymia, depression and anxiety levels. This observation suggests that alexithymia should be taken into consideration when drafting specific psychotherapeutic interventions for these patients.
doi:10.1186/1744-859X-9-16
PMCID: PMC2873300  PMID: 20398249
14.  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
15.  The Relationship of Alexithymia to Emotional Dysregulation Within an Alcohol Dependent Treatment Sample 
Addictive Behaviors  2011;37(4):469-476.
Difficulties regulating emotions have implications for the development, maintenance, and recovery from alcohol problems. One construct thought to impede the regulation of emotion is alexithymia. Alexithymia is characterized by difficulties identifying, differentiating and expressing feelings, a limited imagination and fantasy life, and an externally-oriented thinking style (e.g., prefer talking about daily activities rather than feelings). Given that poor emotion regulation skills have been found to predict posttreatment levels of alcohol use, and that several defining characteristics of alexithymia bear similarity to deficits in emotion regulation skills, it is possible that alexithymia may predict poorer alcohol treatment outcomes. Thus, the present study first examined the relationship of alexithymia to several other emotion regulation measures and then investigated the impact of alexithymia on attrition and alcohol treatment outcomes in men and women (N = 77) enrolled in a 12-week cognitive-behavioral intervention for alcohol dependence. At baseline, higher scores on alexithymia were associated poorer emotion regulation skills, fewer percent days abstinent, greater alcohol dependence severity, and several high-risk drinking situations. Alexithymia was unrelated to attrition and to level of alcohol consumption at posttreatment. Overall, the construct of alexithymia is shown to be related to several theoretically-related constructs (e.g., emotion regulation, mindfulness) but demonstrated a limited relationship to drinking outcomes in those seeking treatment for alcohol dependence.
doi:10.1016/j.addbeh.2011.12.011
PMCID: PMC3288528  PMID: 22244705
Alexithymia; affect regulation; alcohol use disorder; emotion regulation; mindfulness
16.  Dissecting empathy: high levels of psychopathic and autistic traits are characterized by difficulties in different social information processing domains 
Individuals with psychopathy or autism spectrum disorder (ASD) can behave in ways that suggest lack of empathy towards others. However, many different cognitive and affective processes may lead to unempathic behavior and the social processing profiles of individuals with high psychopathic vs. ASD traits are likely different. Whilst psychopathy appears characterized by problems with resonating with others’ emotions, ASD appears characterized by problems with cognitive perspective-taking. In addition, alexithymia has previously been associated with both disorders, but the contribution of alexithymia needs further exploration. In a community sample (N = 110) we show for the first time that although affective resonance and cognitive perspective-taking are related, high psychopathic traits relate to problems with resonating with others’ emotions, but not cognitive perspective taking. Conversely, high ASD traits relate to problems with cognitive perspective-taking but not resonating with others’ emotions. Alexithymia was associated with problems with affective resonance independently of psychopathic traits, suggesting that different component processes (reduced tendency to feel what others feel and reduced ability to identify and describe feelings) comprise affective resonance. Alexithymia was not associated with the reduced cognitive perspective-taking in high ASD traits. Our data suggest that (1) elevated psychopathic and ASD traits are characterized by difficulties in different social information processing domains and (2) reduced affective resonance in individuals with elevated psychopathic traits and the reduced cognitive perspective taking in individuals with elevated ASD traits are not explained by co-occurring alexithymia. (3) Alexithymia is independently associated with reduced affective resonance. Consequently, our data point to different component processes within the construct of empathy that are suggestive of partially separable cognitive and neural systems.
doi:10.3389/fnhum.2013.00760
PMCID: PMC3826592  PMID: 24294197
psychopathy; autism spectrum disorder; alexithymia; empathy; affective resonance; cognitive perspective-taking
17.  The relationship between alexithymia, shame, trauma, and body image disorders: investigation over a large clinical sample 
Background
The connections between eating disorders (EDs) and alexithymia have not been fully clarified. This study aims to define alexithymia’s connections with shame, trauma, dissociation, and body image disorders.
Methods
We administered the Dissociative Experience Scale-II, Trauma Symptom Inventory, Experience of Shame Scale, Toronto Alexithymia Scale-20, and Body Uneasiness Test questionnaires to 143 ED subjects. Extensive statistical analyses were performed.
Results
The subjects showed higher scores on alexithymia, shame, dissociation, and traumatic feelings scales than the nonclinical population. These aspects are linked with each other in a statistically significant way. Partial correlations highlighted that feelings of shame are correlated to body dissatisfaction, irrespective of trauma or depressed mood. Multiple regression analysis demonstrates that shame (anorexic patients) and perceived traumatic conditions (bulimic and ED not otherwise specified) are associated with adverse image disorders.
Conclusion
Shame seems to hold a central role in the perception of an adverse self-image. Alexithymia may be interpreted as being a consequence of previous unelaborated traumatic experiences and feelings of shame, and it could therefore be conceptualized as a maladaptive–reactive construct.
doi:10.2147/NDT.S34822
PMCID: PMC3579461  PMID: 23550168
eating disorders; trauma; alexithymia; shame; body image
18.  The role of alexithymia in the development of functional motor symptoms (conversion disorder) 
Background
The mechanisms leading to the development of functional motor symptoms (FMS) are of pathophysiological and clinical relevance, yet are poorly understood.
Aim
The aim of the present study was to evaluate whether impaired emotional processing at the cognitive level (alexithymia) is present in patients affected by FMS. We conducted a cross-sectional study in a population of patients with FMS and in two control groups (patients with organic movement disorders (OMD) and healthy volunteers).
Methods
55 patients with FMS, 33 patients affected by OMD and 34 healthy volunteers were recruited. The assessment included the 20-item Toronto Alexithymia Scale (TAS-20), the Montgomery-Asberg Depression Rating Scale, the Reading the Mind in the Eyes’ Test and the Structured Clinical Interview for Personality Disorders.
Results
Alexithymia was present in 34.5% of patients with FMS, 9.1% with OMD and 5.9% of the healthy volunteers, which was significantly higher in the FMS group (χ2 (2)=14.129, p<0.001), even after controlling for the severity of symptoms of depression. Group differences in mean scores were observed on both the difficulty identifying feelings and difficulty describing feelings dimensions of the TAS-20, whereas the externally orientated thinking subscale score was similar across the three groups. Regarding personality disorder, χ2 analysis showed a significantly higher prominence of obsessive-compulsive personality disorder (OCPD) in the FMS group (χ2 (2)=16.217, p<0.001) and 71.4% of those with OCPD also reached threshold criteria for alexithymia.
Conclusions
Because alexithymia is a mental state denoting the inability to identify emotions at a cognitive level, one hypothesis is that some patients misattribute autonomic symptoms of anxiety, for example, tremor, paraesthesiae, paralysis, to that of a physical illness. Further work is required to understand the contribution of OCPD to the development of FMS.
doi:10.1136/jnnp-2013-307203
PMCID: PMC4173967  PMID: 24610939
NEUROPSYCHIATRY
19.  Somatic Symptoms Evoked by Exam Stress in University Students: The Role of Alexithymia, Neuroticism, Anxiety and Depression 
PLoS ONE  2013;8(12):e84911.
Objective
The etiology of somatization is incompletely understood, but could be elucidated by models of psychosocial stress. Academic exam stress has effectively been applied as a naturalistic stress model, however its effect on somatization symptoms according to ICD-10 and DSM-IV criteria has not been reported so far. Baseline associations between somatization and personality traits, such as alexithymia, have been studied exhaustively. Nevertheless, it is largely unknown if personality traits have an explanatory value for stress induced somatization.
Methods
This longitudinal, quasi-experimental study assessed the effects of university exams on somatization — and the reversal of effects after an exam-free period. Repeated-observations were obtained within 150 students, measuring symptom intensity before, during and after an exam period, according to the Screening for Somatoform Symptoms 7-day (SOMS-7d). Additionally, self-reports on health status were used to differentiate between medically explained and medically unexplained symptoms. Alexithymia, neuroticism, trait-anxiety and baseline depression were surveyed using the Toronto-Alexithymia Scale (TAS-20), the Big-Five Personality Interview (NEO-FFI), the State Trait Anxiety Inventory (STAI) and Beck’s Depression Inventory (BDI-II). These traits were competitively tested for their ability to explain somatization increases under exam stress.
Results
Somatization significantly increased across a wide range of symptoms under exam stress, while health reports pointed towards a reduction in acute infections and injuries. Neuroticism, alexithymia, trait anxiety and depression explained variance in somatization at baseline, but only neuroticism was associated with symptom increases under exam stress.
Conclusion
Exam stress is an effective psychosocial stress model inducing somatization. A comprehensive quantitative description of bodily symptoms under exam stress is supplied. The results do not support the stress-alexithymia hypothesis, but favor neuroticism as a personality trait of importance for somatization.
doi:10.1371/journal.pone.0084911
PMCID: PMC3867544  PMID: 24367700
20.  Age and gender effect on alexithymia in large, Japanese community and clinical samples: a cross-validation study of the Toronto Alexithymia Scale (TAS-20) 
Background
The construct validity of alexithymia and its assessment using the 20-item Toronto Alexithymia Scale (TAS-20) in Japan is unknown. Low reliability has been found for the third factor of the TAS-20 in some cultures, and the factor structure for psychosomatic disorder patients has not been adequately investigated. Although alexithymia most likely has certain developmental aspects, this has infrequently been investigated.
Methods
The newly-developed Japanese TAS-20 was administered to a normative sample (n = 2,718; 14–84 y.o.), along with the NEO Five-Factor Inventory (NEO-FFI) for cross validation. Psychosomatic patients (n = 1,924, 12–87 y.o.) were tested to evaluate the factor structure in a clinical sample. College students (n = 196) were used for a test-retest study. Internal reliability and consistency were assessed, and the factorial structure was evaluated using confirmatory and exploratory factor analyses for both the normative and the clinical samples. The correlations between the TAS-20 and the NEO-FFI factor scores were evaluated. Age-related and gender differences in the TAS-20 were explored using analysis of variance in the normative sample.
Results
The original three-factor model of the TAS-20 was confirmed to be valid for these Japanese samples, although a 4-factor solution that included negatively keyed items (NKI) as an additional factor was more effective. Significant correlations of the TAS-20 with the NEO-FFI were found, as has been previously reported. Factor analyses of the normative and patient samples showed similar patterns. The TAS-20 total, difficulty in identifying feelings (DIF), and difficulty in describing feelings (DDF) scores were high for teenagers, decreased with age, and from 30s did not change significantly. In contrast, externally oriented thinking (EOT) scores showed an almost linear positive correlation with age. DIF scores were higher for females, while EOT scores were higher for males, without any interaction between gender and age differences.
Conclusion
The original three-factor concept of the TAS-20 was generally supported for practical use. Age-related differences in TAS-20 scores indicate developmental aspects of alexithymia. Alexithymia is made up of two components with different developmental paths: DIF/DDF and EOT.
doi:10.1186/1751-0759-1-7
PMCID: PMC1838425  PMID: 17371586
21.  The Connection between Alexithymia and Somatic Morbidity in a Population of Combat Veterans with Chronic PTSD 
Acta Informatica Medica  2013;21(1):7-11.
Purpose
To investigate the connection between alexithymia and somatic illness, or, somatization, in veterans suffering from chronic combat-related post-traumatic stress disorder, PTSD.
Methods
Croatian combat veterans (N=127) were studied at the Department of Psychology, Zagreb Clinical Hospital Center. The diagnosis of PTSD was confirmed and verified according to the International Classification of Diseases (ICD-10). A version of the Mississippi Scale for Combat Related PTSD (M-PTSD) standardized for the Croatian population was used to assess the severity of PTSD. In addition to the clinical interview, the existence of alexithymia was confirmed by the score on the Toronto Alexithymia Scale (TA S-20).
Results
A statistically significant association was found between the total number of diagnosed physical illnesses and the scores on three subscales of an alexithymia questionnaire, the TA S-20, with a 1% risk (p<0.01, 0.487; 0.450; 0.335). Regression analysis confirmed the most statistically significant predictive value of the first item of the TA S-20, which refers to difficulty in identifying feelings (=0.408, p=0.019). The total score on the M-PTSD scale correlated significantly to the subscales for alexithymia. There was a statistically significant negative correlation of the total score on the M-PTSD scale with social support.
Conclusion
The total scores obtained in this study, particularly those related to alexithymia, indicate the importance of this construct in the etiopathogenesis of somatic morbidity in the study population and confirm that as in other countries the TA S-20 is a useful instrument in Croatia for the assessment of this phenomenon.
doi:10.5455/AIM.2013.21.7-11
PMCID: PMC3610587  PMID: 23572853
alexithymia; PTSD; psychophysiological disorder; somatization disorder; Croatia
22.  Psychological factors in patients with peptic ulcerand functional dyspepsia 
Background: The role of psychological factors in peptic ulcer disease (PUD) and functional dyspepsia (FD) has not been clearly determined. In this study the role of conflict management styles, psychiatric symptoms, and alexithymia were assessed in patients with PUD and FD and in the healthy individuals.
Methods: Ninety subjects [30 PUD (15 women, 15 men), 30 FD (15 women, 15 men), and 30 healthy individuals (15 women, 15 men)] in two endoscopy wards of Babol University of Medical Sciences were evaluated. Three groups were matched with regard to demographic variables. Conflict management styles, psychiatric symptoms, and alexithymia were evaluated by appropriate questionnaires.
Results: The patients with PUD reported less mean scores on psychiatric symptoms than the FD patients (depression 12.6±7.5 vs 28±9.5, anxiety 8.2±5.9 vs 18.7±6. obsessive-compulsive disorder 15.7±7.5 vs 21.8±8.4, interpersonal sensitivity 9.5±7.4 vs 16±7, psychoticism 8.03±4.5 vs 14.3±6.3, somatization 12.5±10.8 vs 20.7±8.1, and the total score of psychiatric symptoms 94.4±49.9 vs 160.1±46.6). The mean scores use of unconstructive conflict management styles in PUD patients were lower than FD (dominating 17.7±3.5 vs 20.2±2.7, avoiding 17.5±3 vs 23.8±4.4). Alexithymia symptoms were higher in FD patients than PUD individuals (difficulty in identifying feelings 23.5±6.3 vs 27.8±3.9, difficulty in describing feeling 16.5±4.4 vs 17.3±3.6). The PUD and FD patients had higher scores regarding these variables than the healthy subjects.
Conclusion: The results show that both PUD and FD patients experienced more psychiatric symptoms, unconstructive conflict management styles, and alexithymia than the healthy subjects. FD patients had worse psychiatric problems than PUD.
PMCID: PMC3992231  PMID: 24778780
Peptic ulcer disease; Functional dyspepsia; Conflict management; Psychiatric symptoms; Alexithymia.
23.  Alexithymia, emotional empathy, and self-regulation in Anorexia Nervosa 
BACKGROUND
During starvation, individuals with Anorexia Nervosa (AN) experience poor awareness of personal emotions (alexithymia), difficulty understanding others’ mental states (cognitive empathy), and poor regulation of personal emotions (self-regulation). Despite its important role in social interaction and interpersonal relationships, emotional empathy has not been measured in AN. Furthermore, how weight affects relationships among alexithymia, empathy, and self-regulation has not been investigated.
METHODS
Women with AN were tested longitudinally during starvation (N=26) and after weight restoration (N=20) and compared to 16 age-matched healthy women at comparable time-points. The Toronto Alexithymia Scale 20 (TAS-20) assessed alexithymia and the Interpersonal Reactivity Index (IRI) measured empathy. Self-regulation was assessed by a subset of 37 items from the MMPI 2.
RESULTS
Relative to comparison participants, AN participants at starvation and weight restoration reported greater alexithymia and personal distress (a domain of emotional empathy measuring vicarious negative arousal to others’ suffering). Among AN participants, personal distress was positively correlated with alexithymia and negatively correlated with self-regulation, when accounting for depression.
CONCLUSIONS
This study provides evidence that alexithymia and personal distress may represent vulnerability features of AN. Higher levels of personal distress in AN may be related to poor self-regulation and emotional awareness.
PMCID: PMC3880788  PMID: 23638441
Anorexia Nervosa; social cognition; alexithymia; empathy; self-regulation; weight effects
24.  Psychomotor retardation and externally oriented thinking in major depression 
Objective
To investigate possible correlations between the tendency towards alexithymia and the depressive state, globally and with regard to the Toronto Alexithymia scale (TAS-20) subscales and the Hamilton rating scale for depression (HAM-D) subscales.
Methods
75 patients, suffering from Unipolar Depression, were assessed through the HAM-D and the TAS-20 and compared to the control group (n = 63). Both groups were divided into two subgroups (30–60 years old; 61–80 years old). Correlations between the tendency towards alexithymia and depressive symptoms, globally and with regard to the TAS-20 subscales and the HAM-D subscales, were investigated.
Results
With regard to patients, a positive correlation was found between: the HAM-D total score and the TAS-20 total score; the HAM-D factor V (psychomotor retardation) and the TAS-20 total score; the TAS-20 subscale III (externally oriented thinking) and the HAM-D total score. In addition a positive correlation between the HAM-D factor V and the TAS-20 subscales I and III was found and confirmed among females. In patients aged 30–60 years, the HAM-D factor V was correlated with all the TAS-20 subscales. As to the control group, a positive correlation was found between: the HAM-D factor I (anxiety/somatization) and the TAS-20 total score; the TAS-20 subscale I and the HAM-D total score; the HAM-D factor I and the TAS-20 subscale. The latter was confirmed in the control group aged 30–60 years.
Conclusion
The link between alexithymia and affective symptoms has been confirmed in the patients and in the control group. An interesting data is the correlation between psychomotor retardation and externally oriented thinking among the patients. According to cognitive theories, psychomotor retardation could be related to feelings of incapacity perceived by an individual. A patient, with an externally oriented thinking, might run into a distorted perception of his own ability to function, thus causing a psychomotor “fattening”.
doi:10.2147/NDT.S44650
PMCID: PMC3671799  PMID: 23745046
alexithymia; major depression; externally oriented thinking; psychomotor retardation; correlation alexithymia and depression
25.  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

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