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1.  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
2.  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
3.  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
4.  Longitudinal study of alexithymia and multiple sclerosis 
Brain and Behavior  2013;4(1):75-82.
Objective
The aim of this study was to investigate the course of alexithymia and its relation with anxiety and depression in patients with multiple sclerosis (MS), over a period of 5 years.
Methods
Sixty-two MS patients were examined at two timepoints, 5 years apart, and they answered questionnaires collecting socio-demographic, medical, and psychological data (depression, anxiety, alexithymia).
Results
Our data show that emotional disorders remain stable over time in patients with MS, particularly as regards alexithymia and anxiety. Conversely, the rate of depression decreased between the two evaluations, falling from 40% to 26%. The two dimensions of alexithymia (i.e., difficulty describing and difficulty identifying feelings) were correlated with anxiety and depression, whereas the third component of alexithymia (externally oriented thinking) was independent, and was the only component to change over time, with a significant fall observed at 5 years.
Conclusion
Alexithymia was associated with increased severity of anxiety and attack relapses.
doi:10.1002/brb3.194
PMCID: PMC3937709  PMID: 24653957
Alexithymia; anxiety; depression; longitudinal study; multiple sclerosis
5.  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
6.  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
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 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
9.  Comparison of psychopathology in the mothers of autistic and mentally retarded children. 
Journal of Korean Medical Science  2002;17(5):679-685.
The aim of this study was to evaluate anxiety, depression, alexithymia, and general psychological symptoms in the mothers of autistic children in comparison with those in the mothers of mentally retarded children. Forty mothers of autistic children and 38 mothers of mentally retarded children were included in the study. After a clinical interview, psychometric tests were performed for depression, anxiety, alexithymia, and Symptom Distress Check List (SCL-90) for general psychological symptoms. Non-depression rates was 27.5% in the mothers of autistic children whereas the rate was 55.3% in the mothers of mentally retarded children. There was no difference regarding anxiety and alexithymia between the two groups. The psychopathology in the mothers of autistic children was more frequent than in those of mentally retarded children in all sub-scales of SCL-90 (somatization obsessive-compulsive, interpersonal sensitivity, depression, anxiety, anger-hostility, phobic anxiety, paranoid thought, psychotism, and extra scale). The mothers of autistic children experienced more psychological distress than those of mentally retarded children. Our findings indicates that the assessment of autistic and mentally retarded children should include psychological assessment of their mothers.
PMCID: PMC3054944  PMID: 12378023
10.  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
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.  ‘Pseudoneurological’ symptoms, dissociation and stress-related psychopathology in healthy young adults 
BMC Psychiatry  2013;13:149.
Background
Somatoform dissociation is a specific form of dissociation with somatic manifestations represented in the form of ‘pseudoneurological’ symptoms due to disturbances or alterations of normal integrated functions of consciousness, memory or identity mainly related to trauma and other psychological stressors. With respect to the distinction between psychological and somatoform manifestations of dissociation current data suggest a hypothesis to which extent mild manifestations of ‘pseudoneurological’ symptoms in healthy young population may be linked to stress-related psychopathological symptoms or whether these symptoms more likely could be attributed to unexplained somatic factors.
Methods
With this aim we have assessed the relationship between somatoform dissociation and stress-related psychopathology (i.e. anxiety, depression, symptoms of traumatic stress, alexithymia) in a group of 250 healthy non-psychiatric and non-clinical young adults.
Results
Results of this study show that the symptoms of somatoform dissociation are significantly linked to stress-related psychopathology.
Conclusions
Findings of this study show that the ‘pseudoneurological’ symptoms may be linked to stress-related psychopathological processes which indicate that also mild levels of stress may influence somatic feelings and may lead to various somatoform dissociative symptoms.
doi:10.1186/1471-244X-13-149
PMCID: PMC3667100  PMID: 23705894
Alexithymia; Anxiety; Depression; Somatoform dissociation; Stress
13.  Alexithymia and fibromyalgia: clinical evidence 
This review proposes a critical discussion of the latest studies investigating the presence of alexithymia in patients with fibromyalgia (FM) and its relation to other psychological disorders. The focus is on the most relevant literature exploring the relationship between FM, a chronic pain syndrome, and alexithymia, an affective dysregulation, largely observed in psychosomatic diseases. The articles were selected from the Medline/Pubmed database using the search terms “Fibromyalgia,” “Alexithymia,” and “Psychological Distress.” Of the seven studies fulfilling these criteria, one found no differences between FM patients and the control group, four found significant differences, with higher levels of alexithymia in the FM sample, while two showed unclear results. Overall, the majority of findings highlighted the high prevalence of alexithymia in FM patients. Future studies should clarify the role of alexithymia in FM, paying attention to two principal aspects: the use, as a control group, of patients with chronic pain conditions but a low psychosomatic component, and the use of other measures, in addition to the Toronto Alexithymia Scale (TAS-20), to assess alexithymia.
doi:10.3389/fpsyg.2013.00909
PMCID: PMC3845661  PMID: 24348453
fibromyalgia; alexithymia; emotional dysregulation; depression; anxiety
14.  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
15.  ALEXITHYMIA AND APATHY IN PARKINSON’S DISEASE: NEUROCOGNITIVE CORRELATES 
Behavioural neurology  2013;27(4):10.3233/BEN-129021.
Non-motor symptoms such as neuropsychiatric and cognitive dysfunction have been found to be common in Parkinson’s disease (PD) but the relation between such symptoms is poorly understood. We focused on alexithymia, an impairment of affective and cognitive emotional processing, as there is evidence for its interaction with cognition in other disorders. Twenty-two non-demented PD patients and 22 matched normal control adults (NC) were administered rating scales assessing neuropsychiatric status, including alexithymia, apathy, and depression, and a series of neuropsychological tests. As expected, PD patients showed more alexithymia than NC, and there was a significant association between alexithymia and disease stage. Alexithymia was associated with performance on non-verbally mediated measures of executive and visuospatial function, but not on verbally mediated tasks. By contrast, there was no correlation between cognition and ratings of either depression or apathy. Our findings demonstrate a distinct association of alexithymia with non-verbal cognition in PD, implicating right hemisphere processes, and differentiate between alexithymia and other neuropsychiatric symptoms in regard to PD cognition.
doi:10.3233/BEN-129021
PMCID: PMC3815995  PMID: 23242364
Non-motor symptoms; basal ganglia; ACC; frontostriatal; right hemisphere
16.  Anxiety Sensitivity and Aspects of Alexithymia Are Independently and Uniquely Associated with Posttraumatic Distress 
Journal of traumatic stress  2009;22(2):131-138.
Using a sample of adult survivors of physical trauma requiring hospitalization (N = 677), we examined the relationship of aspects of alexithymia and anxiety sensitivity to symptoms of posttraumatic distress (PTD). At the bivariate level, both aspects of alexithymia and anxiety sensitivity were positively associated with acute PTD symptomatology, but anxiety sensitivity was more strongly related to PTD symptoms. At the multivariate level, both anxiety sensitivity and aspects of alexithymia made unique and independent contributions to both total PTD symptoms and the majority of PTD symptom clusters. At the facet level, anxiety sensitivity Physical Concerns and Psychological Concerns, and the alexithymic dimension of Difficulty Identifying Feelings, were uniquely associated with acute PTD symptoms. Findings are discussed in terms of potential clinical implications.
doi:10.1002/jts.20397
PMCID: PMC2894609  PMID: 19301252
17.  The predictive value of the Toronto Alexithymia Scale among patients with asthma 
Journal of psychosomatic research  2002;53(6):1049-1052.
Objective
The present study examines how alexithymia, self-report of symptoms, and pulmonary function are related to each other among a sample of patients with asthma. The goal was to extend previous research showing that alexithymia may complicate treatment of asthma.
Methods
Seventy-four participants with asthma completed the Toronto Alexithymia Scale (TAS), Asthma Symptom Checklist (ASC), Taylor Manifest Anxiety Scale (TMAS), and spirometry testing.
Results
The “Difficulty identifying feelings” subscale (IDE) of the TAS was associated with increased report of emotional symptoms (panic–fear) as well as physical symptoms (fatigue) during the past week, but not pulmonary function on the day of testing. This relationship appeared to be influenced by trait anxiety. The “Difficulty communicating feelings” subscale (COM) was correlated with decreased pulmonary function, but not report of emotional or physical sensations experienced during the prior week. The “Externally oriented thinking” subscale (EOT) was not related to any of the dependent measures.
Conclusion
These data suggest that alexithymia may complicate optimal management of asthma and this relationship is best studied by examining the subscales of the TAS separately.
PMCID: PMC2958695  PMID: 12479985
Alexithymia; Asthma
18.  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
19.  Alexithymia and its impact on quality of life in a group of Brazilian women with migraine without aura 
Background
Migraine is a type of primary headache widely known for its impact on quality of life of patients. Although the psychological aspects of the disease are receiving increasing attention in current research, some of them, as alexithymia, are still seldom explored. This study aimed to provide evidence on the relationships between markers of depression, anxiety, alexithymia, self-reflection, insight and quality of life in migraine.
Methods
Forty female outpatients from a Brazilian specialized headache hospital service and a paired control group were compared.
Results
The results revealed that women with migraine had higher levels of depression, anxiety and alexithymia, and lower levels of quality of life, self-reflection and insight, compared to controls. Quality of life in women with migraine was predicted by levels of depression and one alexithymia factor (ability to express emotions and fantasies). A binary regression analysis between clinical and control groups revealed the migraine group to comprise individuals with high anxiety, low quality of life in the physical domain and the presence of a concrete thinking style.
Conclusions
The results highlight the relevance of considering psychological variables in the routine healthcare practices for migraine patients in general, while keeping steady attention to individual case features.
doi:10.1186/1129-2377-14-18
PMCID: PMC3620425  PMID: 23565860
Migraine; Alexithymia; Self-reflection; Insight; Quality of life
20.  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
21.  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
22.  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
23.  Alexithymia in Neurodegenerative Disease 
Neurocase  2011;17(3):242-250.
We investigated alexithymia, a deficit in the ability to identify and describe one’s emotions, in a sample that included patients with neurodegenerative disease and healthy controls. In addition, we investigated the relationship that alexithymia has with behavioral disturbance and with regional gray matter volumes. Alexithymia was examined with the Toronto Alexithymia Scale-20, behavioral disturbance was assessed with the Neuropsychiatric Inventory, and regional gray matter volumes were obtained from structural magnetic resonance images. Group analyses revealed higher levels of alexithymia in patients than controls. Alexithymia scores were positively correlated with behavioral disturbance (apathy and informant distress, in particular) and negatively correlated with the gray matter volume of the right pregenual anterior cingulate cortex, a region of the brain that is thought to play an important role in self and emotion processing.
doi:10.1080/13554794.2010.532503
PMCID: PMC3278303  PMID: 21432723
24.  Alexithymia and its association with burnout, depression and family support among Greek nursing staff 
Background
Few studies have examined the relation between alexithymia (i.e. the inability to recognize and verbalize emotions) and professional burnout. Considering the absence of relevant studies in the Greek scientific literature, the aim of this work was to examine the associations of alexithymia with the three facets of professional burnout, the perception of family support and depression in nursing personnel.
Methods
The study was performed in one of the largest hospitals in Greece and included 95 nurses. Assessments of alexithymia, burnout, depression and family support were made by means of the Toronto Alexithymia Scale, the Maslach Burnout Inventory, the Beck Depression Inventory and the Julkunen Family Support Scale, respectively. Student's t-test, Pearson's correlation and stepwise linear regression were used for the evaluation of data.
Results
Alexithymia was correlated positively with depression, emotional exhaustion and depersonalization, and negatively with sense of family support and personal achievement. Additionally, family support was correlated positively with personal achievement and negatively with depression.
Conclusion
In the scientific literature there is a debate as to whether alexithymia is a stable personality characteristic or if it is dependent on symptoms of mental disorders. We tried to interpret the associations of alexithymia with professional burnout, depressive symptoms and family support. From this study it appears very likely that alexithymia is directly associated with depression and personal achievement, but also - indirectly - with the sense of family support.
doi:10.1186/1478-4491-7-72
PMCID: PMC2730051  PMID: 19671188
25.  Alexithymia and illness behaviour among female Indian outpatients with multiple somatic symptoms 
Indian Journal of Psychiatry  2003;45(4):229-233.
Sixty Indian muslim women outpatients with multiple somatic complaints of nonorganic origin were assessed for alexithymia and abnormal illness behavior using the Toronto Alexithymia Scale (TAS) and the Illness Behaviour Assessment Schedule (IBAS). Alexithymia represented by TAS scores correlated best with the IBAS variables of communication of affect, somatic illness causal beliefs and denial. Correlation with other IBAS variables was modest to poor.There was no correlation of IBAS variables with age of patient, duration of illness or nature of diagnosis: somatoform disorder or anxiety and depressive disorders, The study showed that alexithymia and illness behaviour are overlapping constructs and confirmed the usefulness of TAS as an instrument to discriminate between patients with anxiety/ depressive disorders and somatoform disorders
PMCID: PMC2952369  PMID: 21206863
Alexithymia; Illness behaviour; Somatization

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