Examining the Incremental Validity of the Perth Alexithymia Questionnaire (PAQ) Relative to the 20-Item Toronto Alexithymia Scale (TAS-20).

The 20-item Toronto Alexithymia Scale (TAS-20) is the most widely used instrument for assessing alexithymia, with more than 25 years of research supporting its reliability and validity. The items that compose this scale were written to operationalize the components of the construct that are based on clinical observations of patients and thought to reflect deficits in the cognitive processing of emotions. The Perth Alexithymia Questionnaire (PAQ) is a recently introduced measure and is based on a theoretical attention-appraisal model of alexithymia. An important step with any newly developed measure is to evaluate whether it demonstrates incremental validity over existing measures. In this study using a community sample (N = 759), a series of hierarchical regression analyses were conducted that included an array of measures assessing constructs closely associated with alexithymia. Overall, the TAS-20 showed strong associations with these various constructs to which the PAQ was unable to add any meaningful increase in prediction relative to the TAS-20. We conclude that until future studies with clinical samples using several different criterion variables demonstrate incremental validity of the PAQ, the TAS-20 should remain the self-report measure of choice for clinicians and researchers assessing alexithymia, albeit as part of a multi-method approach.

Revisiting the Concept of Pensée Opératoire: Some Conceptual, Empirical, and Clinical Considerations.

The concept of pensée opératoire (operational thinking) was introduced by French psychoanalysts in 1963 and a decade later was included as an essential component of the alexithymia construct as formulated by the U.S. analysts John Nemiah and Peter Sifneos. Despite a large body of research on alexithymia, the pensée opératoire component is not well understood, especially among clinicians and researchers who are not familiar with French psychoanalytic literature. In this article we clarify the definition and metapsychological conceptualization of the concept, review findings from some relevant empirical studies, and critique a recent proposal for redefining the alexithymia construct that departs from the original understanding of pensée opératoire. We also discuss some clinical implications of the concept and some strategies that psychotherapists can employ in the treatment of patients with this mode of thinking.

A bifactor analysis of the 20-item Toronto Alexithymia Scale: Further support for a general alexithymia factor.

The 20-Item Toronto Alexithymia Scale (TAS-20) is the most widely used measure to assess the personality construct of alexithymia and is composed of three-factor analytically derived subscales. These subscales measure and represent three critical, theoretically based facets of alexithymia. The subscales are distinct, yet highly interrelated and only as a collective body do they reflect adequately the alexithymia construct. Although different studies using both university student and community samples suggest that TAS-20 total scores are largely reflective of variation on a single construct, and that subscale scores do not provide unique and reliable information beyond total scores, many users of the scale frequently continue to employ and even rely more heavily on subscale scores rather than total scale scores when interpreting research study outcomes. Our goal in this study is to provide clinicians and researchers with replicable psychometric information for the TAS-20 estimated from bifactor modeling in an attempt to provide further support for using total rather than subscale scores. In general, our findings were consistent with previous studies indicating that TAS-20 total scores can be considered indicative of a single construct. The replication of these earlier results from previous investigations provides additional support for the use of a total TAS-20 score and questions the utility of using TAS-20 subscale scores. Based on these results, we recommend that researchers and clinicians use a single total TAS-20 score and not subscale scores. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

An evaluation of alexithymia subtypes using latent profile analysis.

Four subtypes of the alexithymia construct have been proposed based on different response patterns to the Cognitive and Affective dimensions of the Bermond-Vorst Alexithymia Questionnaire (BVAQ). Previous studies investigating whether alexithymia subtypes can be statistically estimated have not found complete support for these specific subtypes. These previous studies, however, contained several methodological limitations such as relatively small sample sizes, and considerations of only a limited number of proposed subtypes. In the current investigation, we examined whether the four proposed subtypes could be statistically detected in a large sample of undergraduate students (N = 612) who completed the BVAQ, using latent profile analysis (LPA). Based on observed responses to the five BVAQ subscales, consistent with previous studies, our results did not find support for the four proposed alexithymia subtypes. Rather, our results suggested LPA solutions that correspond to individuals with various degrees of alexithymia 'severity'. Although further studies are needed, especially with clinical samples, these results question the idea of four alexithymia subtypes and suggest that the implementation of these subtypes into various research studies may be a premature endeavour.

Development and psychometric evaluation of an informant form of the 20-item Toronto alexithymia scale.

OBJECTIVE: The alexithymia personality construct encompasses difficulties identifying and describing feelings, restricted imaginal processes, and an externally oriented cognitive style. The construct was derived initially from observations of patients with classic psychosomatic diseases. The self-report 20-item Toronto Alexithymia Scale (TAS-20) is the most frequently used measure to assess alexithymia. A concern associated with the TAS-20 is whether individuals can accurately self-report difficulties identifying and describing feelings if they are deficient in those abilities. To address this issue, we sought to develop and validate an informant form (version) of the TAS-20, the 20-item Toronto Alexithymia Scale - Informant Form (TAS-20-IF). METHOD: We employed a three-phase methodological strategy. In the first phase, items from the TAS-20 were re-written into a third person version by a team of experts. In the second phase, the "traditional" three-factor structure was tested in the TAS-20-IF using confirmatory factor analysis in a large sample of young adults (N = 857). The third phase was conducted with another sample (N = 430) composed of "informants" (n = 215), who completed the TAS-20-IF, and "targets" (n = 215), who completed the TAS-20 (informants were nominated by the targets). RESULTS: The psychometric properties (items and scales) of both versions were adequate and the three-factor structure of the TAS-20-IF was supported; the correlation between the two versions was statistically significant and the factor structures were similar. CONCLUSION: Although further research is needed to replicate these findings, especially in clinical samples, the results support the reliability and validity of the TAS-20-IF.

Twenty-five years with the 20-item Toronto Alexithymia Scale.

OBJECTIVE: Twenty-five years ago, this journal published two articles reporting the development and initial validation of the 20-Item Toronto Alexithymia Scale (TAS-20). Since then the literature on alexithymia has burgeoned with the vast majority of this research using the TAS-20, including multiple language translations of the scale. METHOD: In this article we review the psychometric literature evaluating various aspects of the reliability and validity of the TAS-20 and examine some of the controversies surrounding the scale and the construct it assesses. We reflect on the ways in which the TAS-20 has advanced the measurement of the construct and theory of alexithymia. We also discuss recent developments and some future directions for the measurement of alexithymia. RESULTS: Although not without some controversy, the preponderance of the accumulated evidence over a 25-year period supports various aspects of the reliability and validity of the TAS-20, including findings from confirmatory factor analytic and convergent and discriminant validity studies which are consistent with Nemiah et al.'s (Nemiah et al., 1976 [3]) and Taylor and colleagues (Taylor et al., 1997 [9]) theoretical formulations and definition of the alexithymia construct. CONCLUSIONS: Based on the accumulated empirical evidence of 25 years, we conclude that the TAS-20 is a reliable and valid instrument and accurately reflects and measures the construct as it was originally defined by Nemiah et al. Nemiah et al. (1976) [3] as composed of deficits in affect awareness and expression and pensée opératoire (operational thinking). Clinicians and researchers can use the TAS-20 to confidently measure alexithymia, the roots of which have foundations in psychosomatic medicine.

Creativity and Perversion: Waiting for the Muse.

Although there is an extensive psychoanalytic literature on perversion, and numerous articles about creativity, few authors have explored relations between creativity and perversion. In particular, the role of childhood trauma and its impact on object relations has not been examined in patients with perversions whose creativity is blocked. In association with preoedipal anxieties and fantasies, childhood trauma can not only contribute to the development of perversion, but can also inhibit or distort the creative process by establishing an inner world characterized by the presence of a threatening internal bad object and the elusiveness of an internal good object. Though it is essential to help these patients establish an identification with the phallic father, an internal good maternal object, in the form of a muse, needs to be retrieved to bring inspiration and reduce the anxieties generated by an internal bad object, thereby facilitating the pursuit of authentic creative work. A detailed case report illustrates how this theoretical perspective guided the treatment approach to a male patient with macrophilia who was struggling to realize his creative potential.

Some Comments on the Alternative Universe of the Trump Administration.

The psychoanalytic concept of an "anal universe" is a type of alternative universe in which reality is denied and falsehood prevails. This essay demonstrates how this concept illuminates much of the confusion and distortion of truth generated by the Trump administration. The author comments on several behaviors of President Trump and his administration including perverse thinking and lying, mocking disabled people, demeaning women, labeling journalists as enemies of the people, encouraging regressive forces in groups, and promoting policies that cruelly affect immigrants and refugees. The author also comments on the primacy of the male phallus in American politics. He contrasts the spatial metaphor of an "anal universe," where there is distortion of language and an absence of moral constraints and ethical principles, with the metaphor of a feminine psychic space, which enhances the capacity for symbolic thinking and the generation of creative ideas and solutions.

Taxometric Analysis of the Toronto Structured Interview for Alexithymia: Further Evidence That Alexithymia Is a Dimensional Construct.

Alexithymia is a clinically relevant personality construct characterized by difficulties identifying and describing feelings, externally oriented thinking, and impoverished imaginal processes. Previous taxometric investigations provided evidence that alexithymia is best conceptualized as a continuous dimension rather than a discrete type, at least when assessed with the self-report 20-Item Toronto Alexithymia Scale. The aim of the current study was to test the categorical versus dimensional structure of alexithymia using the recently developed Toronto Structured Interview for Alexithymia. Three nonredundant taxometric procedures (MAXCOV, MAMBAC, and L-Mode) were performed on the Toronto Structured Interview for Alexithymia subscale scores from a multinational sample of 842 adults. All taxometric procedures produced unambiguously dimensional solutions, providing further evidence that the core alexithymia features are continuously distributed in the population. Discussion focuses on the theoretical, assessment, and clinical implications of these findings for the alexithymia construct.

Developing a short version of the Toronto Structured Interview for Alexithymia using item response theory.

The Toronto Structured Interview for Alexithymia (TSIA) was developed to provide a structured interview method for assessing alexithymia. One drawback of this instrument is the amount of time it takes to administer and score. The current study used item response theory (IRT) methods to analyze data from a large heterogeneous multi-language sample (N = 842) to investigate whether a subset of items could be selected to create a short version of the instrument. Samejima's (1969) graded response model was used to fit the item responses. Items providing maximum information were retained in the short model, resulting in the elimination of 12-items from the original 24-items. Despite the 50% reduction in the number of items, 65.22% of the information was retained. Further studies are needed to validate the short version. A short version of the TSIA is potentially of practical value to clinicians and researchers with time constraints.

Relationships among alexithymia, therapeutic alliance, and psychotherapy outcome in major depressive disorder.

Previous studies have found that alexithymia predicts process and outcome of psychodynamic psychotherapy across a range of psychiatric disorders. There is preliminary evidence that alexithymia may exert its effects on outcome through the therapist. Other studies have found that alexithymia does not influence outcome of cognitive-behavioral therapy (CBT). The aim of the current study was to investigate the capacity of alexithymia to predict therapist- and patient-rated therapeutic alliance and response to CBT and interpersonal psychotherapy (IPT) for major depressive disorder. A total of 75 adults with major depressive disorder were randomized to receive weekly sessions of manualized individual CBT or IPT for a period of 16 weeks. Pre-treatment alexithymia exhibited a positive direct effect on depression change, and a negative indirect effect on depression change via patient-rated alliance at week 13. There was no mediating role of therapist-rated alliance. Although these findings are preliminary, they suggest that pre-treatment alexithymia has meaningful links to psychotherapy process and outcome, and that nuanced analyses incorporating intervening variables are necessary to elucidate the nature of these links.

Impact of a Cognitive Behavioral Intervention on Health-Related Quality of Life and General Heart Rate Variability in Patients Following Cardiac Surgery: An Effectiveness Study.

BACKGROUND: Although there is evidence supporting the efficacy of cognitive-behavioral therapy (CBT) in decreasing psychologic symptoms and improving health-related quality of life in patients who have undergone coronary artery bypass graft surgery, the effectiveness of these interventions in usual health care practice, and their effect on general heart rate variability (HRV), has not been tested. OBJECTIVE: This study investigated the effectiveness of CBT in improving health-related quality of life and HRV in patients with postcardiac surgery. METHODS: However, 2 months following surgery, 150 patients were assigned sequentially to a CBT group that received the intervention for 9 months or a comparison group that received usual care. Patients were assessed at baseline and after 10 months with the 36-item Short Form Health Survey. HRV was also assessed. RESULTS: In total, 43 patients in the CBT group and 46 in the usual care group completed the study. The CBT group demonstrated significant improvements in health-related quality of life and significant increases in general HRV. Significant group-by-time interaction effects were found for the several 36-item Short Form Health Survey scales and mental component summary and a time-domain HRV parameter indicating that the pattern of change in scores over time differed significantly between the 2 groups. CONCLUSION: CBT administered in a "real-world" clinical setting can effectively improve health-related quality of life and the general HRV in patients who have undergone cardiac surgery.

An Examination of the Topology and Measurement of the Alexithymia Construct Using Network Analysis.

There is some ongoing controversy surrounding the definition and measurement of the alexithymia construct. Whereas most researchers describe 4 components comprising the construct (difficulty identifying feelings, difficulty describing feelings, restricted fantasizing, and externally oriented thinking), some include a 5th component, which is defined as "reduced experiencing of emotional feelings." This study examined the topology and measurement of alexithymia using the method of network analysis with data from a heterogeneous multilanguage sample (N = 1,696) that had completed the Bermond-Vorst Alexithymia Questionnaire (BVAQ; Vorst & Bermond, 2001 ). The BVAQ includes an Emotionalizing subscale for assessing the purported 5th component; we compared the network analyses conducted both with and without the Emotionalizing items. The results revealed strong associations between Emotionalizing and Analyzing (externally oriented thinking) items, but Emotionalizing items had almost as many negative as positive connections with items assessing the other components of the construct. A comparison of communities identified by modularity analyses of the 2 networks failed to support emotionalizing as a distinct component of the construct. In addition, network metrics revealed that Fantasizing items were particularly weak within both networks, suggesting that reduced fantasizing might be a peripheral component of the alexithymia construct. Implications for the measurement and treatment of alexithymia are discussed.

What's in the name 'alexithymia'? A commentary on "Affective agnosia: Expansion of the alexithymia construct and a new opportunity to integrate and extend Freud's legacy.".

The recent proposal of a new type of agnosia termed 'affective agnosia' extends Freud's legacy and captures the concept of not knowing one's own emotions. This concept links well with the theory of levels of emotional awareness and maps onto a hierarchical model of neural substrates of emotional experience, but does not encompass the pensée opératoire component of the alexithymia construct. Moreover, identifying agnosia and anomia subtypes, which connotes a categorical conceptualization of alexithymia, is inconsistent with the dimensional nature of the construct. We describe a more widely accepted definition of alexithymia, and argue that although aptly descriptive, the concept of affective agnosia does not advance the theory, measurement, and treatment of alexithymia. A review of alexithymia literature indicates that impairment in the mental representation of emotions has been a central aspect of alexithymia theory since the concept was introduced, and guided the development of the Toronto Alexithymia Scale and other measures of the construct. Moreover, techniques to enhance mentalization of emotions have been used by psychotherapists for several decades.

Varieties of Castration Experience: Relevance to Contemporary Psychoanalysis and Psychodynamic Psychotherapy.

Although Freud considered castration to be one of the two major anxieties of human life, the castration complex has been relatively neglected in contemporary psychoanalytic writing and is insufficiently discussed in presentations of clinical cases. This article discusses the relevance of the concept to contemporary psychoanalysis and psychodynamic psychotherapy, in particular the important contributing role of castration conflicts in the pathogenesis of a wide range of clinical symptoms. The author begins by briefly reviewing some classical and contemporary psychoanalytic ideas about castration to show how the concept has broadened and is currently used not only to signify fear of damage to or loss of the genital, but also metaphorically to indicate a threat to or loss of any valued human characteristic or function. He outlines Brenner's distinction between castration anxiety and castration depression, and reviews the role of childhood trauma in intensifying castration conflicts. He then illustrates the clinical application of these ideas by describing aspects of his psychotherapeutic work with three male patients who presented with a variety of symptoms and distressing psychological experiences that were gradually resolved through the analysis of underlying castration anxiety and/or castration depression. Although castration anxiety is frequently intermingled with separation anxiety, the author concludes that with many traumatized patients castration conflicts are in the foreground and the therapist needs to focus on the patient's proneness to humiliation, powerlessness, and shame.

Illuminating the theoretical components of alexithymia using bifactor modeling and network analysis.

Alexithymia is a multifaceted personality construct that reflects deficits in affect awareness (difficulty identifying feelings, DIF; difficulty describing feelings, DDF) and operative thinking (externally oriented thinking, EOT; restricted imaginal processes, IMP), and is associated with several common psychiatric disorders. Over the years, researchers have debated the components that comprise the construct with some suggesting that IMP and EOT may reflect constructs somewhat distinct from alexithymia. In this investigation, we attempt to clarify the components and their interrelationships using a large heterogeneous multilanguage sample (N = 839), and an interview-based assessment of alexithymia (Toronto Structured Interview for Alexithymia; TSIA). To this end, we used 2 distinctly different but complementary methods, bifactor modeling and network analysis. Results of the confirmatory bifactor model and related reliability estimates supported a strong general factor of alexithymia; however, the majority of reliable variance for IMP was independent of this general factor. In contrast, network analysis results were based on a network comprised of only substantive partial correlations among TSIA items. Modularity analysis revealed 3 communities of items, where DIF and DDF formed 1 community, and EOT and IMP formed separate communities. Network metrics supported that the majority of central items resided in the DIF/DDF community and that IMP items were connected to the network primarily through EOT. Taken together, results suggest that IMP, at least as measured by the TSIA, may not be as salient a component of the alexithymia construct as are the DIF, DDF, and EOT components. (PsycINFO Database Record