Temporal stability and differential relationships with neuroticism and extraversion of the three subscales of the 20-item Toronto Alexithymia Scale in clinical and nonclinical samples

OBJECTIVES: To examine the cross-sample and temporal stability of the three subscales of the 20-item Toronto Alexithymia Scale (TAS-20) and to study the pattern of associations between the TAS-20 scales, neuroticism, and alexithymia. METHODS: Two clinical and three nonclinical samples were included in the cross-sectional part of the study. One clinical and one nonclinical sample also participated in the 6-month follow-up study. To test the replicability of the three-factor structure of the TAS-20 across samples, a principal component analysis was conducted, followed by a Procrustes rotation. Linear regression analyses were conducted to examine temporal stability and to determine the specificity of the associations among the TAS-20 scales, neuroticism, and extraversion. RESULTS: The three-factor structure of the TAS-20 was confirmed across all five samples. With a few exceptions, neuroticism and extraversion attained a higher level of temporal stability than the alexithymia scales. The TAS-subscale measuring difficulty identifying feelings (DIF) was less stable in the clinical than in the nonclinical sample. Neuroticism was most strongly associated with DIF, whereas extraversion was mainly related to externally oriented thinking (EOT). A combination of both neuroticism and extraversion was the best predictor of difficulty describing feelings (DDF). CONCLUSIONS: Future studies on the psychometric properties and the clinical value of the TAS-20 should pay more attention to its subscales. Especially the EOT facet needs further examination.     

Alexithymia in parents of daughters with eating disorders: its relationships with psychopathological and personality variables

OBJECTIVES: The purpose of this research was to investigate alexithymia among parents of a daughter with eating disorders (EDs) and to relate alexithymia to personality and psychopathology characteristics. METHODS: Parents of 73 women with ED (20 with anorexia nervosa, restrictive subtype (ANR), 23 with anorexia nervosa, bulimic subtype (ANB) and 30 with bulimia nervosa (BN)) and parents of 72 normal women were evaluated with the Toronto Alexithymia Scale (TAS-20), the Eysenck Personality Questionnaire, the Beck Depression Inventory and the Self-Rating Anxiety Scale. RESULTS: The parents of daughters with ED show higher scores in the TAS-20 and its factors than the controls. TAS-20 scores of parents are associated with neuroticism, anxiety and depression. CONCLUSIONS: Alexithymia in parents of daughters with an ED could be a trait of personality, but it could also be a state due to distress. Alexithymia should be taken into account in order to help these parents express emotions.     

Alexithymia and personality in relation to social anxiety among university students

The aims of the present study were to investigate the relationship of social anxiety symptoms with alexithymia and personality dimensions in university students and to control the effects of depression and anxiety on this relationship. A total of 319 university students (85 males and 234 females) from two different universities in Ankara were investigated with the Liebowitz Social Anxiety Scale (LSAS), the Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI), the Toronto Alexithymia Scale (TAS-20) and the Temperament and Character Inventory (TCI). We found that subscales of the LSAS (fear or anxiety and avoidance) were positively correlated with depression and alexithymia and “difficulty in identifying feelings” (DIF) and “difficulty in describing feelings” (DDF) subscales of the TAS-20. Harm avoidance (HA) showed positive correlations with subscales of the LSAS, whereas self-directedness (SD) showed negative correlations with these subscales. High TAS-20 DDFand HA and low SD predicted fear or anxiety LSAS subscale scores, whereas high TAS-20 DDF, HA and depression scores were predictors for LSAS avoidance subscale scores. Although our sample is not representative of the whole Turkish university student population, we conclude that both fear or anxiety and avoidance were mainly interrelated with DDF and HA, although the causal relationship is not clear.     

Independent associations of alexithymia and social support with depression in hemodialysis patients

OBJECTIVE: The influences of alexithymia and social support on depression among chronically ill patients were examined prospectively. METHODS: The study population was 230 outpatients receiving chronic hemodialysis (HD) therapy. The Beck Depression Inventory-II (BDI-II), the 20-item Toronto Alexithymia Scale (TAS-20), and two subscales of the Social Support Questionnaire were given to the subjects. The BDI-II was readministered after a 6-month interval, and subjects who showed deterioration in their depression score above the level predicted from their baseline score were identified. Multivariate logistic analysis adjusted for age, gender, cause of dialysis, and psychosocial variables were performed. RESULTS: Baseline depression was significantly and independently associated with alexithymia and low satisfaction with available support. Deterioration of depression after 6 months was predicted by alexithymia and poor available support. CONCLUSIONS: Alexithymia and reduced social support might have independent associations with the presence and the prognosis of depression among HD patients.     

Age is strongly associated with alexithymia in the general population

OBJECTIVE: We studied the prevalence of alexithymia, its distribution in different age groups in a wide age range, its association with sociodemographic and health-related variables, and its co-occurrence with depression. METHODS: The study forms part of the Health 2000 Study. The original sample comprised 8028 subjects representing the general adult population of Finland. Alexithymia was measured with the 20-item Toronto Alexithymia Scale (TAS-20), and depression was measured with the 21-item Beck Depression Inventory. Altogether, 5454 participants filled in TAS-20 in their mother tongue. RESULTS: The prevalence of alexithymia was 9.9%. Men (11.9%) were more commonly alexithymic than women (8.1%). Alexithymia was associated with male gender, increasing age, low educational level, poor perceived health, and depression. CONCLUSIONS: The findings were in line with earlier population studies. For the first time, it was possible to analyze the prevalence of alexithymia in a wide age range (30-97 years). International comparative studies are needed.     

Observer- and self-rated alexithymia in eating disorder patients: levels and correspondence among three measures

OBJECTIVES: Our objectives were to evaluate the psychometric properties of the Observer Alexithymia Scale (OAS) in eating disorder patients, alexithymia severity across diagnostic subgroups, and correspondence among three alexithymia measures. METHOD: Seventy-five women, each with an eating disorder diagnosis, completed two alexithymia self-reports, the 20-item Toronto Alexithymia Scale (TAS-20) and the Bermond-Vorst Alexithymia Questionnaire-version B (BVAQ-B), and asked a relative or an acquaintance to rate them using the OAS. RESULTS: The OAS showed acceptable discriminant validity and interrater reliability. Patients' OAS scores were higher than scores reported for people-in-general samples and lower than those for outpatient clinical samples. No statistically significant OAS, TAS-20, and BVAQ-B score differences were found between the patients with anorexia nervosa restrictive type and those with bulimia nervosa. OAS, TAS-20, and BVAQ-B total scores were moderately, positively, and significantly correlated. CONCLUSION: These clinical data show the psychometric strength of the OAS, which reasonably can be recommended for use with the TAS-20 in research and clinical practice.     

Psychometric properties of the Toronto Alexithymia Scale (TAS-20) for substance users

OBJECTIVE: To determine the psychometric properties of the Toronto Alexithymia Scale (TAS-20), an established self-report measure of alexithymia, for a substance user sample participating in a clinical trial of outpatient cognitive-behavioral therapies (N=230). METHODS: Confirmatory and exploratory factor analyses were used to determine the number and nature of the factors underlying the TAS-20 in a sample of substance users. Structural equation modeling was used to determine the predictive validity of the TAS-20. RESULTS: A factor structure comparable, but not identical, with TAS-20 psychometric results with other populations was found; alpha coefficients were .88 for the feelings factor, .62 for the external thinking factor, and .87 for the total score. Although, on average, the substance users did not appear to have elevated alexithymia scores compared with the undergraduate students, alexithymia predicted less treatment engagement, i.e., fewer sessions attended and weaker helping alliance. Alexithymia also predicted alcohol use outcomes but not drug use outcomes. The relation between alexithymia and drinking outcome was conditional on whether the patient was using solely alcohol at baseline. CONCLUSION: The TAS-20 has reasonably good psychometric properties in this sample, which might be improved by dropping several marginal questionnaire items. Alexithymia appears to attenuate substance abuse treatment engagement. More clinical and research experience with this construct and specific instrument in substance user samples is needed.     

The 20-Item Toronto Alexithymia Scale. IV. Reliability and factorial validity in different languages and cultures

OBJECTIVE: The aim of this paper was to review findings from studies that have evaluated the reliability and factorial validity of the 20-item Toronto Alexithymia Scale (TAS-20) in different languages and cultures. METHOD: Data from published articles as well as unpublished data from various countries were reviewed to determine whether the three-factor structure of the TAS-20 is replicable in different cultures by the method of confirmatory factor analysis (CFA), and whether the scale and its three-factor scales show internal reliability in these cultures. RESULTS: The TAS-20 has been translated adequately into 18 different languages and evaluated by CFA in 19 different countries. There is strong support for the generalizability of the three-factor structure of the scale across languages and cultures. In addition, the full-scale TAS-20 and the first two factors show adequate to good internal reliability for most of the translations. In most cultures where English is not the primary language, however, the third factor lacks internal reliability; this might be due to cultural differences or a response bias to the several negatively keyed items on this factor. CONCLUSION: The findings support the use of the TAS-20 in cross-cultural research, and suggest that alexithymia may be a universal trait that transcends cultural differences.     

Alexithymia and occupational burnout are strongly associated in working population

OBJECTIVE: The relationship between alexithymia and occupational burnout has not previously been studied. We investigated the association between alexithymia and occupational burnout in a representative nationwide population health study. METHODS: This study was a part of the Finnish Health 2000 Study. The nationally representative sample comprised 3322 employees aged 30-64 years. Alexithymia was measured with the 20-item Toronto Alexithymia Scale (TAS-20) and occupational burnout with the Maslach Burnout Inventory-General Survey. Sociodemographic and health-related variables including depression were treated as confounders in the logistic regression analyses, which were performed alternately with TAS-20 total score and the scores of the three TAS-20 factor scales as alexithymia variables. RESULTS: Alexithymia and its three facets were significantly associated with occupational burnout even when controlled for confounding factors. CONCLUSIONS: Even though both alexithymia and depression are associated with burnout, alexithymia may be an independent risk factor for occupational burnout.     

Cross-cultural alexithymia: validity of the 20-item Toronto Alexithymia Scale in North American aboriginal populations

OBJECTIVE: The generalizability of the alexithymia construct to North American aboriginal culture was examined by assessing the replicability of the factor structure of the 20-item Toronto Alexithymia Scale (TAS-20) in two different adult samples. The study also assessed the reliability of the scale and the influence of gender, age, and education on alexithymia levels. METHOD: The first sample was a community-based group of 123 aboriginal men and women; the second sample was 102 male aboriginal offenders. Both samples completed the TAS-20. RESULTS: The replicability of the three-factor structure for the TAS-20 was supported in both groups using confirmatory factor analysis (CFA). The TAS-20 and its three factors demonstrated adequate internal reliability, and the variables of gender, age, and education accounted for small or nonsignificant amounts of variability in total TAS-20 and factor scale scores. CONCLUSION: The results provide additional support for the factorial validity of the TAS-20 in diverse cultural groups.     

Alexithymia and depression: A 1-year follow-up study in outpatients with major depression

Objective: To examine the changes in alexithymic features and depressive and other psychological distress symptoms during a 1-year follow-up among patients with major depression. Methods: The study population comprised 120 outpatients suffering from major depression. Diagnosis was made with Structured Clinical Interview (SCID-I) for DSM-III-R. The severity of depression was evaluated with the 17-item Hamilton Rating Scale for Depression (HAM-D), and self-reported depression with the Beck Depression Inventory (BDI-21). Alexithymic features were assessed with the Twenty-Item Toronto Alexithymia Scale (TAS-20). Self-reported psychological distress symptoms were evaluated with the Brief Symptom Inventory (BSI). Results: Measures of depression and distress were significantly lower at the follow-up than at the baseline, while the total TAS-20 scores did not change significantly during the follow-up. A closer examination revealed that various TAS-20 factors behaved differently. Changes in Factors 1 and 2 were associated with changes in mood, whereas those in Factor 3 were not. Additionally, recovery from depression was associated with decrease in alexithymic features. Conclusion: Difficulties in identifying and in describing feelings are associated with changes in mood, while externally oriented thinking is not.     

Relationships between alexithymia and psychological characteristics associated with eating disorders

This study examines the relationships between alexithymia and psychological characteristics and behaviors that are commonly associated with eating disorders. The 20-item Toronto Alexithymia Scale (TAS-20) and the Eating Disorder Inventory (EDI) were administered to a group of 48 female patients with anorexia nervosa, a matched comparison group of 30 normal women, and an unmatched comparison group of 116 male and 118 female university students. In the anorexic and male student groups, the TAS-20 correlated significantly and positively with the EDI subscales, Ineffectiveness, Interpersonal Distrust, Interoceptive Awareness, and Maturity Fears. The TAS-20 correlated significantly only with Interpersonal Distrust in the matched comparison group, and only with Ineffectiveness and Interpersonal Distrust in the female student group. The results suggest that alexithymia is related to several psychological traits that are characteristic of patients with eating disorders and thought to play a role in the development of the disorders, but is unrelated to attitudes and behaviors concerning abnormal eating and body weight and shape.     

Psychometric properties of the Finnish 20-item Toronto Alexithymia Scale

The aim of this study was to examine the factor structure and the validity of the Finnish version of the 20-item Toronto Alexithymia Scale (TAS-20). As part of the Northern Finland 1966 Birth Cohort Project, the TAS-20 was presented to a sample of 5034 31-year old persons. A confirmatory factor analysis showed that the three-factor model, earlier established with the original TAS-20, was in agreement with the Finnish version of the scale. Three criteria of goodness-of-fit met the standards for adequacy of fit. For the total scale, internal reliability (Cronbach's alpha) was 0.83 and for the three subscales (factors 1, 2, and 3) it was 0.81, 0.77, and 0.66, respectively. Two- and one-factor models for TAS-20 were also examined, but the other models did not perform as well as the three-factor model. The factor model also worked well with a sample of 516 students with a mean age of 24.8 years. In conclusion, the TAS-20 scale is useful in the Finnish version, too.     

The 20-Item Toronto Alexithymia Scale. III. Reliability and factorial validity in a community population

OBJECTIVE: Some researchers have questioned the stability of the three-factor structure of the 20-Item Toronto Alexithymia Scale (TAS-20) or the reliability of one or more factors of the scale. The aim of this study was to assess the replicability of the factor structure of the TAS-20 in a large community sample and to determine also whether the same three-factor structure can be recovered in men and women. The study also assessed the reliability of the scale and the influence of gender, age, and education on TAS-20 scores. METHOD: The TAS-20 was administered to 1933 adults (880 men and 1053 women) residing in several small cities and towns in Ontario, Canada. The factor structure of the scale was assessed using confirmatory factor analysis (CFA). RESULTS: The three-factor structure of the TAS-20 was replicable in the entire community sample and also separately in men and women. The TAS-20 and its three factors demonstrated internal reliability, and the variables of gender, age, and education accounted for relatively small or modest amounts of variability in total TAS-20 and factor scale scores. CONCLUSION: The results provide strong support for the reliability and factorial validity of the TAS-20 and indicate the importance of using CFA when assessing the replicability and theoretical integrity of the factor structure of the scale.     

Cross validation of the factor structure of the 20-item Toronto Alexithymia Scale: An Italian multicenter study

The 20-item Toronto Alexithymia Scale (TAS-20) has been shown in previous research to measure a general dimension of alexithymia with three intercorrelated factors. This study evaluated the reliability and factorial validity of an Italian translation of the TAS-20 in a group of normal adults (N = 206) and in a mixed group of medical and psychiatric outpatients (N = 642). Using confirmatory factor analyses, the previously established three-factor model of the TAS-20 was found to be replicable in both groups. In addition, the Italian TAS-20 demonstrated adequate estimates of internal reliability and test-retest reliability. Although evaluation of the convergent, discriminant, and concurrent validity of the TAS-20 is required in Italian populations, the present results support the use of the Italian translation of the scale for clinical and research purposes.     

Somatoform disorders as disorders of affect regulation: a study comparing the TAS-20 with non-self-report measures of alexithymia

OBJECTIVE: To determine the role of undifferentiated and dysregulated affects in somatoform disorders by using a multimethod assessment approach of alexithymia. METHODS: Forty patients with ICD-10 somatoform disorders (SoD) and 20 healthy controls, matched for age, education and sex, were included in the study. Alexithymia was assessed using the Toronto Alexithymia Scale (TAS-20), the Affect Consciousness Interview (ACI), and the Levels of Emotional Awareness Scale (LEAS). All classifications were made blinded with regard to clinical status. RESULTS: Scores of the ACI and the TAS-20 showed that alexithymia is higher in SoD than in healthy controls. No differences were found on the LEAS. In terms of the multidimensionality of the alexithymia construct, our results indicate a specific positive association between SoD and a proneness to experience undifferentiated affects. The three subfactors of the TAS-20 were differentially related to non-self-report measures of alexithymia and to negative affectivity (NA). Only the cognitive facet of the TAS-20 (externally oriented thinking [EOT]) was related to the LEAS and the ACI. In contrast, the affective facets of the TAS-20-difficulties identifying feelings (DIF) and difficulties describing feelings (DDF)-were substantially related to NA. CONCLUSION: The findings highlight the important role of impaired affect regulation and NA in the process of somatization.     

Alexithymia and its relationships with C-reactive protein and serum lipid levels among drug naïve adult outpatients with major depression

Several studies have investigated the relationship between C-reactive protein (CRP) and serum lipid levels in Major Depression (MD), but no study has, to date, evaluated the impact of alexithymia on these parameters. Therefore, the aim of the present cross-sectional study was to evaluate the relationship between alexithymia, suicide risk, C-reactive protein (CRP) and serum lipid levels in adult outpatients suffering from moderate to severe MD. CRP and serum lipid levels data were analyzed in 145 drug-naïve adult outpatients (69 men, 76 women) with a DSM-IV diagnosis of MD. Alexithymia was measured with the 20-item Toronto Alexithymia Scale (TAS-20), depression severity was evaluated with the 17-item Hamilton Depression Rating Scale (HAM-D) and suicide risk was determined using the Scale of Suicide Ideation (SSI). Alexithymics showed altered serum lipid levels and higher CRP than non-alexithymics. In the linear regression models, lower total cholesterol levels and “Difficulty in Identifying Feelings” dimension of TAS-20 were significantly associated with depression severity, whereas lower high-density lipoprotein levels and “Difficulty in Identifying and Describing Feelings” dimensions of TAS-20 were associated with higher suicide risk. Authors discuss study limitations and future research needs.     

Alexithymia in insulin-dependent diabetes mellitus is related to depression and not to somatic variables or compliance

OBJECTIVES: To assess the prevalence of alexithymia in insulin-dependent diabetic mellitus (IDDM) outpatients. To examine whether alexithymia is associated with diabetic somatic variables, depression, and compliance. METHOD: Our sample comprised 69 diabetic outpatients followed in a university hospital. We assessed the prevalence of alexithymia (26-item Toronto Alexithymia Scale, TAS-26) and the relationships among alexithymia, depression (13-item Beck Depression Inventory, BDI-13), somatic diabetic variables (glycosylated hemoglobin, number of mild or severe hypoglycemia, somatic complications), and compliance (observer-rater scale completed by diabetologist). RESULTS: The prevalence of alexithymia in IDDM patients was low (14.4%). Alexithymia and depression, as measured by TAS-26 and BDI-13 scores, respectively, correlated with each other. Alexithymia was not correlated with glycemic control, somatic complications, or compliance. CONCLUSION: In our sample, alexithymia was related to depression and not to somatic factors or compliance.     

Stability of alexithymia in late adolescence: Results of a 4-year follow-up study

The aim of the present study was to assess the stability of alexithymia in adolescents and the effects of parental factors and social support thereon. The sample comprised 315 late adolescents, of whom 259 were female and 56 male. At baseline, the mean age of the subjects was 19 years (range 17–21 years). The follow-up period was 4 years (2008–2012). The 20-item Toronto Alexithymia Scale (TAS-20) was used for the assessment of alexithymia both at baseline and follow-up. The Multidimensional Scale of Perceived Social Support (MSPSS) and the Parental Bonding Instrument (PBI) were used as measures at baseline. Regarding absolute stability, the changes in the TAS-20 total scores and two subscales (DIF and EOT) were statistically significant but the effect sizes for the changes were small (Cohen?s d 0.21–0.24). The test–retest correlations for the TAS-20 total and subscale scores were high (ρ=0.50–0.64, P<0.001), indicating relative stability. While several parental and social support variables were associated with alexithymia at baseline, low social support from friends was the only to predict higher alexithymia at follow-up. Alexithymia is a stable personality trait also in late adolescence. Low social support from friends is related to alexithymia in young adulthood.     

An investigation of the construct validity of the 20-Item Toronto Alexithymia Scale through the use of a verbalization task

OBJECTIVE: The construct validity of the 20-Item Toronto Alexithymia Scale (TAS-20) was examined through a verbalization task requiring participants to discuss a past distressing event. METHODS: Verbalizations were transcribed and coded for the frequency and number of different negative and positive emotion words used. Relationships between the TAS-20 and these variables were examined. RESULTS: Controlling for negative affect (NA), the difficulty identifying feelings (DIF) subscale was positively associated with the frequency of negative emotion words used and negatively associated with the frequency and number of different positive emotion words used during the verbalization task. High, compared with low, scoring TAS-20 participants used a lower frequency of and fewer different positive emotion words. CONCLUSION: The TAS-20 may be measuring negative emotional expressivity separate from negative affectivity, as well as a reduced capacity to access and elaborate upon positive emotion. Findings are discussed in regard to improving the conceptualization and measurement of emotional deficits in alexithymia.