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John Nemiah was interested in the impact of emotionally traumatic events on mental and bodily processes and in conceptualizing the psychological defenses and deficits that contribute to the development of psychological and somatic symptoms. He viewed dissociation as the central psychological mechanism in the formation of a spectrum of symptoms, and conceptualized alexithymia as a deficit in the cognitive processing of emotion such that stress-induced arousal could bypass the psyche and produce somatic symptoms. This article briefly reviews some of Nemiah's conceptual ideas and relates them to several new theories and concepts and findings from empirical research. His concept of the 'psychic elaboration' of emotion is consistent with contemporary theories of the cognitive processing of emotions that emphasize the importance of imagery and linguistic symbolizations. Alexithymia is inversely related to mentalization and is associated with insecure attachment styles and emotional trauma, which influence the capacity to regulate affects induced by stressful events. A multiple code theory of emotional information processing links psychological and somatic symptoms to various degrees of dissociation within and between the elements comprising emotion schemas and to compensatory attempts at repair. Recent studies support Nemiah's view that alexithymia and intrapsychic conflicts may both contribute to the pathogenesis of panic attacks. There is also substantial evidence of an association between childhood trauma and the development of somatic disease in adult life. Secure attachments and well-developed capacities for symbolization and affect regulation seem to render individuals more resilient to the traumas and stressful events of everyday life., (Copyright © 2010 S. Karger AG, Basel.)

Background: Despite increasing emphasis on using multiple methods to assess personality constructs in psychosomatic research, previous investigations of relations between alexithymia and type A behavior (TAB) have been limited by the use of single methods of measurement and almost no attempt to assess subcomponents of TAB. The aims of this study were to (1) evaluate levels of agreement between structured interview assessments of alexithymia, TAB, hostility, and time urgency and well-established self-report measures of these constructs, and (2) explore relations between alexithymia and TAB and its subcomponents in patients with coronary heart disease (CHD)., Methods: 62 CHD patients were investigated 6 weeks after coronary angioplasty. Alexithymia was assessed with the Diagnostic Criteria for Psychosomatic Research (DCPR) and the 20-item Toronto Alexithymia Scale (TAS-20). TAB was assessed with the DCPR and the Short Form of the Jenkins Activity Survey Type A scale (JAS-SF). Time urgency was assessed with the DCPR and the Speed/Impatience scale of the Jenkins Activity Survey (JAS-S), and hostility was assessed with the DCPR and the Hostility subscale of the Revised Symptom Checklist-90 (SCL-HOS)., Results: The DCPR classifications showed reasonably high levels of agreement with the TAS-20 and JAS-SF classifications of alexithymia and TAB, but lower levels of agreement in identifying patients with high hostility on the SCL-HOS and high time urgency on the JAS-S. Alexithymia measured by both the DCPR and the TAS-20 was unrelated to both self-report and structured interview measures of TAB, hostility, and time urgency., Conclusions: The DCPR is a suitable screening instrument for assessing alexithymia and TAB, although the two constructs are unrelated., (Copyright 2007 S. Karger AG, Basel.)

Background: Assessments of personality constructs increasingly use self-report and structured interview instruments, which allow for a multimethod measurement approach and decrease specific measurement method bias. The aim of this study was to develop a valid and reliable structured interview for assessing the alexithymia construct., Methods: Sixty interview questions were written initially, each with a set of scoring criteria and prompts and probes to elicit information assisting in the scoring of the respondents' answers., Results: After pilot testing, the number of questions was reduced to 43, which were administered to 136 community participants and 97 psychiatric outpatients. A series of item and scale analyses further reduced the item pool to 24 items. Principal component analysis and confirmatory factor analysis of these 24 items revealed preliminary evidence of a hierarchical, four-factor structure, with four lower factors nested within two higher-order latent factors. This structural configuration resulted in the Toronto Structured Interview for Alexithymia (TSIA) with two domain scales and four facet scales. The TSIA and its six scales demonstrated acceptable levels of interrater, internal, and retest reliability. The TSIA and its scales correlated modestly but significantly with the 20-item Toronto Alexithymia Scale and its three factor scales, providing some support for the concurrent validity of this interview., Conclusion: The TSIA appears to be a promising structured interview for assessing alexithymia., (Copyright 2006 S. Karger AG, Basel.)

Research investigating the alexithymia construct is advancing rapidly and has broadened considerably in recent years as a result of interdisciplinary efforts, new methodologies, and experimental techniques. New developments in the field include a shift from measurement-based validational studies to experimental investigations, which explore the relation between alexithymia and various aspects of emotional processing; the use of functional brain imaging techniques to explore neural activity associated with alexithymia; and experimental studies that measure multiple indices of physiological response to standardized emotion-inducing stimuli. Developmental research and attachment studies are providing ways for investigating potential etiological sources of the construct; and experimental approaches are being used to explore relations between alexithymia and other health-related personality constructs. In addition, longitudinal and treatment studies are clarifying the relation between alexithymia and psychopathology and the extent to which alexithymia predicts treatment outcome. Investigators need to embrace the new methods and techniques for the field of research to further increase understanding of the alexithymia construct and its association with physical and mental illness., (Copyright 2004 S. Karger AG, Basel)

Background: Alexithymia and psychopathology may influence the way individuals experience psychological distress and somatic symptoms. This study evaluated patients referred to psychiatric and gastroenterologic outpatient settings in order to investigate the levels of alexithymia and psychopathology, and the possible role of alexithymia in symptom perception and health care utilization. The association between psychiatric disorders and functional gastrointestinal disorders (FGIDs) was also assessed., Methods: Psychopathology (by the Revised 90-item Symptom Checklist), alexithymia (by the 20-item Toronto Alexithymia Scale), and gastrointestinal symptoms (by the Gastrointestinal Symptom Rating Scale) were evaluated in 52 psychiatric outpatients and 58 medical outpatients with FGIDs. Two comorbid subgroups of 25 psychiatric patients with FGIDs and 38 FGID patients with psychiatric disorders were formed and compared., Results: Forty-eight percent of the psychiatric patients had associated FGIDs, and 65.5% of the FGID patients had associated psychiatric disorders. The FGID patients had significantly less psychopathology, but significantly higher alexithymia and more severe gastrointestinal symptoms, than the psychiatric patients. In the comparison of the two subgroups with comorbidity, FGID patients with psychiatric disorders were still more alexithymic and had less psychopathology than psychiatric patients with FGIDs, but gastrointestinal symptoms were not significantly different., Conclusion: Patients with 'functional' gastrointestinal symptoms attending a medical care service are likely to be highly alexithymic, whereas those attending a psychiatric care service are likely to show severe psychopathology. Alexithymia seems to influence the presentation of 'functional' somatic symptoms and the type of health care utilization., (Copyright 2004 S. Karger AG, Basel)

Background: Previous studies demonstrating an association between alexithymia and depression have led to the proposal that alexithymia may be a state-dependent phenomenon rather than a stable and enduring personality trait. Several longitudinal studies have provided support for a trait view of alexithymia, but most of these studies evaluated absolute stability only (i.e., the extent to which alexithymia scores change over time) and did not examine the relative stability of alexithymia (i.e., the extent to which relative differences among individuals remain the same over time) in the context of changes in illness symptomatology. The present study evaluated both absolute stability and relative stability of alexithymia in depressed patients who experienced a marked reduction in the severity of depressive symptoms., Methods: Forty-six psychiatric outpatients with major depression were assessed for alexithymia and depression with the 20-item Toronto Alexithymia Scale and the Hamilton Rating Scale for Depression at the start of treatment (baseline) and after 14 weeks of treatment (follow-up) with antidepressant medication. Paired t tests and correlational analyses were performed to evaluate absolute stability and relative stability in alexithymia. Hierarchical regression analyses were then used to assess the degree to which the relative stability in alexithymia scores was related to the severity of depressive symptoms, and the degree to which changes in alexithymia scores could be attributed to changes in depression scores., Results: Alexithymia scores changed significantly from baseline to follow-up, indicating a general lack of absolute stability. There was, however, strong evidence of relative stability, as alexithymia scores at baseline correlated significantly with alexithymia scores at follow-up and were also a significant predictor of follow-up alexithymia scores, after partialling the effects of depression severity., Conclusions: Although alexithymia scores may change in the presence of large changes in the severity of depressive symptoms, the finding of relative stability of alexithymia supports the view that this construct is a stable personality trait rather a state-dependent phenomenon., (Copyright 2001 S. Karger AG, Basel.)

Background: Although the alexithymia construct was derived from observations of patients with classical psychosomatic diseases, empirical studies have found only a moderate association between alexithymia and inflammatory bowel disease (IBD). Indeed, there is some evidence that alexithymia may be associated more strongly with functional somatic symptoms than with the psychosomatic diseases. The present study examined the relationship between alexithymia and functional gastrointestinal disorders (FGIDs) in a group of 121 FGID patients, and compared the results with findings from a group of 116 IBD patients and a group of 112 healthy subjects., Method: The subjects completed the 20-item Toronto Alexithymia Scale and the Hospital Anxiety and Depression Scale., Results: The FGID group was significantly more alexithymic than the IBD group, and the two gastrointestinal groups were more alexithymic than the normal healthy group. These differences remained even after controlling for the influence of education, gender, anxiety, depression and gastrointestinal symptoms., Conclusions: The finding of a high rate of alexithymia (66%) in the group of FGID patients is consistent with the propensity of these patients to somatization and to high levels of poorly differentiated psychological distress.

The purported association between alexithymia and inflammatory bowel disease (IBD) was investigated in a group of 112 IBD patients (89 with ulcerative colitis and 23 with Crohn's disease) using the well-validated 20-Item Toronto Alexithymia Scale. Alexithymia was assessed also in a group of 112 normal subjects matched for gender, age, and education. The IBD group was significantly more alexithymic than the control group, and no significant difference was found between the ulcerative colitis and Crohn's disease patients. Alexithymia was unrelated to the duration of illness and the level of disease activity. Although the rate of alexithymia in the IBD group (35.7%) was significantly higher than the rate in the control group (4.5%), it is lower than rates of alexithymia that have been found among psychiatric patients with disorders that also have been linked theoretically and clinically with alexithymia.

Slides of photographs depicting posed facial expressions of nine different emotions were presented to 131 females and 85 males who were asked to identify the emotion(s) being experienced by the person in each photograph. Subjects were then administered the 20-item version of the Toronto Alexithymia Scale; the 33rd and 66th percentiles were used to categorize subjects into high, moderate, and low alexithymia groups. Results showed that the high alexithymia group was significantly less able to recognize facial expressions of emotions than the low alexithymia group. There was no significant effect for gender on the ability to recognize facial emotions. The results suggest the presence of deficits in the perception of nonverbal emotion in alexithymia.

Addressing certain problems with the compositional structure of the self-report Toronto Alexithymia Scale, this paper reports the development of a revised version of the scale as well as results from a preliminary series of studies evaluating its reliability and validity. The Revised Toronto Alexithymia Scale (TAS-R) demonstrated good internal consistency and a stable and replicable two-factor structure that is congruent with the two major dimensions of the alexithymia construct. Evidence of convergent and discriminant validity for the TAS-R was provided by correlations with measures of other constructs. Criterion validity was demonstrated by the ability of TAS-R scores to discriminate between behavioral medicine outpatients designated alexithymic and those designated non-alexithymic on the basis of clinical interview ratings. Normative data are provided for university student, normal adult, and psychiatric outpatient populations.

The relationship between conjugate lateral eye movements (CLEMs) and alexithymia was investigated in a group of 60 (23 male and 37 female) right-handed university students. Subjects completed the Toronto Alexithymia Scale (TAS), the Schalling-Sifneos Personality Scale, and the Basic Personality Inventory, which measures 12 basic dimensions of personality and psychopathology, CLEMs were recorded while subjects were asked 20 general knowledge questions that have no tendency to elicit eye movements predominantly in one direction. A series of gender by CLEM preference (left vs. right mover) ANOVAs were conducted with the various measures. There was a significant relationship between right CLEM preference and higher scores on the TAS, but no relationships between CLEMs and any of the other measures. These results suggest that alexithymia is associated with left cerebral lateralization, and support the hypothesis that alexithymic characteristics reflect a variation in brain organization.

Previous studies have shown that measurement of verbal affective expression is influenced by the method used for obtaining speech samples, thereby supporting a situation-dependent, or state concept of alexithymia. In this study monadic speech samples obtained from 20 psychoneurotic and 20 psychosomatic patients, using selected thematic apperception test (TAT) cards, were examined using different methods of content analysis. Although no differences were found with the Gottschalk-Gleser anxiety, hostility outward and hope scales, the psychosomatic patients had a more limited emotional vocabulary than the psychoneurotic patients as measured by an 'affect vocabulary score' (AVS). In contrast to the Gottschalk-Gleser scores (GGS), the AVS correlated with measures of fantasizing ability and would appear to be a more valid method of measuring alexithymia. The findings also supported a trait concept rather than a state concept of alexithymia.

The Toronto Alexithymia Scale (TAS) is a 26-item self-report measure of alexithymia with good internal consistency and test-retest reliability, and a factor structure congruent with the alexithymia construct. This study assesses the construct validity of the scale by examining its relationship with several personality and psychopathology measures. In a sample of 81 college students, the TAS correlated strongly and positively with a measure of hypochondriasis but negatively with measures of psychological mindedness and 'need for cognition'. There were low-magnitude correlations between the TAS and measures of self-depreciation, social introversion, persecutory ideation, and impulse expression, but no correlation with a measure of denial. These results indicate that the TAS is assessing adequately the theoretical domain relevant to its item and factor structure.

Addressing methodological problems in the development of existing scales for measuring alexithymia, this study reports the development of a new self-report scale. The Toronto Alexithymia Scale (TAS) was devised with concern for theoretical congruence with the alexithymia construct, independence of social desirability response bias, and internal consistency. Initially, 41 items were administered to 542 college students. Twenty-six items meeting preestablished psychometric guidelines were retained. Factor analysis yielded four interpretable factors, all consistent with the construct. The scale demonstrated adequate split-half and test-retest reliability, and scores were not significantly associated with age, education, and socioeconomic status. These preliminary results suggest that the TAS may be used as a clinical screening device with psychiatric and general medical patient populations.

Previous reports have documented the development of the Toronto Alexithymia Scale (TAS) in addition to evaluating its reliability and validity. The present paper describes two studies designed to further evaluate the construct validity of the TAS. In Study I 117 university students completed the TAS and the three subscales of the Short Imaginal Processes Inventory. In Study II 74 students completed the TAS and measures of ego strength, anger expression, and physical symptoms. In both studies the pattern of correlations between the TAS and the various psychological measures converged and diverged in a theoretically meaningful fashion, providing further evidence for the validity of the TAS and of the alexithymia construct.