THE CONSTRUCT OF ALEXITHYMIA
Capece M.[1], Ferraioli C.[2]

1. Dr. Marzia Capece, Psychologist expert in legal psychology, penitentiary and clinical criminology. ↑
2. Dr. Carmen Ferraioli, expert in human sciences, law and criminology. ↑

Abstract: This article aims to explore alexithymia, which is characterized as a deficit in the ability to recognize and process one’s emotions. The analysis mainly focuses on the construct of this emotional illiteracy, which, according to many contemporary theorists, and especially the Toronto Group composed of G. Taylor, J.D.A. Parker, and R. Bagby, is a disorder of emotional regulation, particularly a deficit in the cognitive-exponential domain of emotional response systems and the interpersonal regulation of emotions. The article also examines the current tools available for studying and evaluating the level of alexithymia, such as the Toronto Alexithymia Scale (TAS), the Toronto Alexithymia Scale – 20 (TAS-20), and the Toronto Structured Interview for Alexithymia (TSIA).

Keywords: Emotions – Deficit – Psychosomatic – Communication – Feelings – Caregiver – Emotional Relationships – Toronto Group – Alexithymia Scale.

Introduction

One of the challenges in contemporary neuroscience and psychology research is understanding the emotional process in all its aspects, from biological to psychological ones, first seeking to establish a univocal and accepted definition of what an emotion is and what it involves. The concept of emotion and the related process is highly and implicitly conditioned by the overall vision of the individual and their mental and physiological functioning. The psyche can be considered a conceptual construct that has undergone a long journey throughout the centuries, initially in ancient Greece, where it meant “the life of the body,” that is, the main structure of the body that generates life, before acquiring a purely mental meaning and later a strictly biological one, particularly in modern times. Researchers focusing on the mind now aim to align the psychological approach with natural sciences. This alignment allows for the use of scientifically valid, reliable, and generalizable methods and theoretical foundations, but it also risks overlooking the subjective aspects inherent in emotional experience (Galati, 2020).

Thanks to James’ contribution with his somatic theory of emotions, and later the empirical research by Damasio, the psyche and its more subjective aspects regained their place within the mind, becoming closely connected to the body. This holistic view of the individual, considering both aspects of the body and mind, is now commonly accepted. Despite the lack of a univocal definition, contemporary sciences agree that emotions have both somatic and psychic components, defining them as the quintessential somatopsychic and psychosomatic element (Epifanio et al., 2014). Identifying, classifying, and translating an emotional experience allows an individual to self-regulate their internal states and act according to a motivational framework based on their developmental experiences. When these processes do not occur, it can be said that we are facing a psychological functioning referred to as “Alexithymia.” Alexithymia, literally meaning “lack of words for emotions,” is a concept initially theorized to describe the clinical situation of patients suffering from “psychosomatic” disorders due to difficulty in identifying and expressing their emotions and discomfort. Linking psychosomatic symptoms to the idea that they stem from the inability to “translate emotions into words” was widely accepted in common usage and especially aligned with older conceptions. These conceptions posited that symptoms, particularly physiological ones without an apparent cure, were seen as unresolved intrapsychic conflicts, or psychosomatic disorders.

The basis of this view was the idea that the awareness and sharing of an emotion happen through language, which makes the contents of the mind explicit. Therefore, it is through translating an emotional experience into words that it becomes possible to reflect upon it and gain clearer awareness of the emotional experience. If this does not occur, the emotion remains “trapped” at the bodily level without a mental representation, and thus manifests as somatic symptoms. However, today it is impossible to conceive of an individual as a system in which one element acts unidirectionally upon another. Instead, the individual is identified as an open system that can be influenced by intrapsychic, relational, and social situations. In this context, the term “psychosomatic”, in the clinical sense, becomes fundamental because it attempts to place every symptom of a person correctly within the framework of their life context.

With the growth of empirical research on alexithymia, a construct defined by Nemiah and Sifneos in 1970, there is now consensus in understanding this psychological functioning as a personality dimension characterized by a cognitive deficit related to emotional processes. This deficit is attributed to a disruption in the creation and development of the primary relationship with the caregiver. In this sense, alexithymia can be considered a risk factor not only for somatic pathologies but also for mental disorders. Thus, alexithymia can be an excellent example of the importance for individuals to translate and interpret emotions and the physiological changes related to them, so they can organize and regulate their emotional lives effectively.

This article aims to explore the concept of alexithymia in light of the most recognized theories on the mind-body unity, highlighting the relationship between emotional expression and the manifestations and symptoms related to psychosomatic pathologies.

The Alexithymic Construct

The identification of alexithymia as a clinical dimension originates from clinical observations made on patients suffering from classical psychosomatic illnesses (such as ulcers, asthma, eczema, hypertension, etc.). Paul MacLean (1949), for example, noticed the presence of a clear inability in many psychosomatic patients to verbalize their emotions, which he explained through his “triune brain” model.

Using this model, MacLean hypothesized that, in these patients, emotions were unable to reach the lower nervous centers and the neocortex (the verbal brain), thus compromising the possibility of using symbolic language for emotional expression. Jurgen Ruesch (1948) observed psychological and behavioral characteristics in psychosomatic patients that suggested an “infantile personality.” These patients exhibited: a passive thinking style, dependence, and imitation; rigid moral consciousness; primitive and stereotypical fantasies; difficulty with verbal expression and recognizing emotions. Anticipating concepts developed many years later, Ruesch suggested that early relational difficulties might have caused a halt in emotional and psychological development.

It was Sifneos in 1973, after a series of interviews with patients suffering from classical psychosomatic illnesses, who coined the term alexithymia (from Greek a = lack, lexis = word, thymos = emotion), which translates to “emotion without words” or “lack of words for emotions.” This term was used to refer to:

• A difficulty in verbally expressing emotions.
• Limited fantasizing activity.
• A colorless communication style (when questioned about emotions felt during a stressful event, these patients tended to give a detailed description of the event without any reference to the emotions experienced).

The initial belief that such characteristics were peculiar to psychosomatic illnesses and the debate on whether alexithymia should be considered a stable personality trait or a temporary pathological state resulting from illness, seem to have dissolved in light of significant research that favors the view of alexithymia as a transnosographic clinical dimension, extending along a continuum from normal to pathological depending on the level of difficulty in understanding and communicating emotional experiences.

Recent research has revealed the presence of alexithymic symptoms in the general population, in post-traumatic stress disorder, substance addiction, and eating disorders. Cases of alexithymia have also been observed in patients with severe depressive disorders who complain of incomprehensible physical pain, and in patients with sexual perversions.

In all these cases, researchers have found that many individuals exhibit a serious impairment in integrating cognitive and emotional factors. What emerges in alexithymic subjects is, therefore, not the presence of inhibitory dynamics that lead to the splitting of the ideational from the affective component and the subsequent repression of the latter into the unconscious; rather, the person is simply unable to translate emotions into words and name them.

It is important to clarify that alexithymia is not a categorical phenomenon of the “all or nothing” type, as if it were a general inability to recognize emotions. Instead, it is a dimensional construct (or personality trait): some individuals present “alexithymic areas of the mind,” that is, related to specific content, emotions, or situations.

The various studies conducted since the introduction of the alexithymia construct have identified the following characteristics in alexithymic subjects:

• Difficulty discriminating between emotions and distinguishing them from somatic sensations.
• A limited emotional vocabulary, which leads to considerable difficulty in verbally communicating emotions to others.
• Deficient or absent fantasizing activity.
• An externally oriented cognitive style.

According to Apfel and Sifneos (1979), alexithymic subjects exhibit a colorless communication style, lacking references to inner experiences, desires, fears, and feelings. Based on further clinical observations, a series of accessory characteristics have been added, as they are not part of the core theoretical concept of alexithymia:

• Somatic symptoms.
• Explosive anger or unwarranted crying.
• Expression of emotions through actions.
• Rare dreams that oscillate between primitive nightmares and rational thinking.
• An impression of pseudonormality; they sometimes seem to follow an instruction manual.
• Amnesia.
• Fluctuation between dependent and avoidant behavior.
• Reduced empathic capacity: they are unable to use their own or others’ emotions as signals.

In alexithymic subjects, a clear difficulty in mentalizing their internal mental states emerges, leading them to regulate their emotions through impulsive acts or compulsive behaviors (such as overeating, substance abuse, or paraphilias). It is evident that a compromise in the cognitive processing of emotions has significant repercussions on interpersonal relationships.

Krystal, for example, highlighted the inability of alexithymic individuals to empathize with others, a consequence of their difficulty in recognizing emotions. This inability translates into a tendency to isolate themselves from social reality or to develop highly dependent relationships with high interchangability.

Regarding the genesis of alexithymia, Shaffer (1993) hypothesized that the compulsive demand for care is linked to childhood histories in which alexithymic subjects experienced insecure attachment to their caregiver. Similarly, Crittenden (1994) hypothesized that good emotional development is closely correlated with secure childhood attachment experiences. Growing up in a secure relational context indeed facilitates the process of integrating affective and cognitive information.

The influence of attachment styles on the development of the capacity to regulate affect is also fundamental in Fonagy’s (2001) work, particularly when using the concept of reflective function or mentalization to describe the representational nature of one’s own and others’ mental states—constructing representations of feelings, thoughts, desires, and beliefs, and reflecting on one’s intentions and those of others. Fonagy argues that the capacity for mentalization is closely linked to affect regulation, a competence that develops when the child grows within a relationship with a caregiver who is able to reflect on the child’s emotional needs, in order to contain and name them. When the caregiver is incapable of reverie, the child is not supported in the mental growth that allows them to acquire the ability to develop a mental representation of an emotion. As Fonagy himself argues, “The development of the capacity to represent the mental world of the other is closely linked to the regulation and control of affect. The ability to represent an affect is crucial for achieving control over overwhelming affective states. In the absence of this capacity, the affective dimension of the other can only be recognized through direct experience via emotional resonance.”

Thus, emotion risks becoming overwhelming and a source of subsequent trauma.

The Role of Early Relationships in Affect Regulation

It is implicit that the development of affect and the cognitive abilities needed to regulate them is closely connected to the mother-child relationship. The caregiver, generally the mother, is able to respond with care and deep emotional expressions, facial or otherwise, which in turn help to organize or regulate the emotional life of the child.

The sharing or mirroring of emotions, particularly positive ones, and the experience of safety in the early family environment, play an important role in the child’s emotional development and the formation of their representations of the self and the object.

Normal emotional development cannot take place when parents are unable to read the child’s emotional cues and fail to assume the role of external regulators of the child’s emotional states.

Affective regulation is an active process that involves the neurophysiological, behavioral, and cognitive-experiential dimensions. Affective regulation or dysregulation is characterized by pre-objectual relationships.

Pre-objectual relationships, which by their nature are preverbal, sensorimotor, emotional, and concrete, develop in the child before conscious reflective awareness of the self and others as separate individuals. Therefore, they are a precursor to the ability to “read” both one’s own mental states and those of others.

Pre-objectual experiences include partial spaces, the object-self, the transitional object, and bizarre objects.

From a Freudian perspective, anxiety is a dynamic generated by the conflicting relationships of the ego with its objects, both before and after the child’s acquisition of the ability to consciously identify the separate existence of their objects or the self.

Freud’s assertion implies a model of affect regulation based not only on a theory of internalized object relations but also on a theory of pre-objectual relations.

In 1926, Freud stated that archaic emotional experiences serve as the foundation for normal or pathological emotional development.

Anna Freud (1981) made some modifications to the theory of the anxiety signal to describe how the defenses of the ego can be triggered by both distress and anxiety.

According to Krystal (1988), all affects can function as signals. When the child develops a subjective awareness of their being in relation to an external object perceived as capable of alleviating intolerable affects, they develop the ability to intentionally send signals of help to that person.

This interaction is eventually internalized and culminates in the child’s ability to recognize and regulate their own affects. These reactions represent the initiation of an ego defense to reduce tension and restore homeostatic balance.

Thus, Freud, with the theory of the anxiety signal, radically changes his previous hypothesis concerning the affects involved.

In this new perspective, that part of the ego which constantly explores both the external and internal environment, sensing the imminence of danger, sends a signal of anxiety charged with affect. The part of the ego that receives and understands this signal as a sign of anxiety alters its behavior defensively to protect itself from the anticipated danger.

The ego’s ability to both send and receive danger signals that modify its behavior comes from the mother-child relationship.

The gradual internalization of these interactions, which the child is pre-structured to build, largely determines the subsequent ability or inability to regulate affects.

Freud’s theory describes the pre-representational precursors of what later develops into the differentiated structures of self and object representations.

The pre-representational phase refers to an innate ability of the newborn that precedes and makes possible the development of the semiotic function necessary for re-presentation as conscious and unconscious thought.

The Toronto Group

We improperly define the “Toronto Group” as the research team formed by Graeme J. Taylor, R. Michel Bagby, and James D. A. Parker, although not all members of the group live and work in Toronto.

Taylor is a psychoanalyst, a professor of psychotherapy at the University of Toronto, and at the Mount Sinai Hospital in Toronto.

Bagby is an expert in psychometrics, a professor at the same university, and the head of the Division of Personality and Psychopathology at the “Centre for Addiction and Mental Health” at the Clarke Institute.

Parker is a clinical psychologist, a professor of psychology, and the head of the Emotion and Health Research Centre at Trent University in Peterborough, Ontario.

It would be more accurate to refer to them as the “Ontario Group,” but the geographical identification is primarily due to the widespread use of the most important alexithymia assessment scale developed by the group, the Toronto Alexithymia Scale.

The Toronto Group represents one of the best examples of the approach to research in psychosomatics and psychology in general. The different theoretical-methodological orientations represented by the three authors reflect a fundamental philosophy in alexithymia research.

Over the last 15-20 years, the group has investigated the construct of alexithymia through their respective specializations and the ability to integrate different competencies around a common long-term research protocol.

Taylor is the theoretical soul of the group. His main interest is to explore the construct of alexithymia in relation to modern psychoanalytic theories of early object relations and self-structure.

Bagby and Parker represent the operational soul of experimental psychology and psychometric assessment, i.e., the validation of the theoretical construct through experimental protocols and measurement tools.

This philosophy of multidisciplinarity and integration in research is central to the group’s scientific policy.

The Canadian group has never closed itself off but has always encouraged collaboration with researchers from around the world, to the point of becoming the reference point for dozens of international research groups.

This is a distinctly secular research attitude, free of any type of prejudice, which allows for the broadest open-mindedness toward all aspects of investigation.

Alexithymia and the Toronto Group

The construct of alexithymia is essentially known as the difficulty in identifying, describing, and communicating emotions, distinguishing between emotional experiences and physiological activation of emotions, the poverty of imaginative processes, a cognitive style oriented towards the factual and external reality, and a conformist social adaptation.

Born in the early 1970s from the observation of patients with classic psychosomatic illnesses (Sifneos), the construct has evolved, expanded, and diversified over its 30-year history, with the Toronto group being the primary protagonist in this evolution, taking over from original authors like Sifneos and Nemiah.

To understand the core of the alexithymia construct, it is crucial to make a conceptual distinction between two English terms, which are difficult to translate into Italian without losing the complexity of their respective meanings: emotions and feelings.

Emotions are innate biological phenomena, genetically programmed, mediated by subcortical and limbic systems, functional to the survival of the species, and based on non-verbal signals such as facial expressions, gestures, body posture, and tone of voice. They are essentially the biological component of affect.

Feelings, on the other hand, are much more complex individual psychological phenomena as they involve cognitive processing and subjective experience mediated by neocortical functions. This psychological component of affect allows one to evaluate the emotional response to external and interpersonal stimuli and to intentionally communicate emotions through the verbal and non-verbal linguistic function of symbolism.

Thus, feelings depend on one’s culture, childhood experiences, representations of the self and others, memories, fantasies, and dreams.

Therefore, alexithymia does not refer to individuals without emotions, but to subjects with a deficit in the psychological component of affect, that is, people who have emotions expressed by the biological components of affect but with little or no ability to use psychological tools (images, thoughts, fantasies) to represent them (Taylor, 2004).

The term alexithymia is thus a name for a disorder already well identified in the late 1940s by Ruesch and MacLean, who noticed that patients suffering from classic psychosomatic diseases or chronic conditions exhibited marked difficulties in the verbal and symbolic expression of their feelings, and they hypothesized that these characteristics were due to a developmental arrest in personality. They considered this deficit to be “the central problem of psychosomatic medicine.”

The same clinical aspects were also noted by many authors such as Fenichel, Horney, Kelman, Modell, Winnicott, and McDougall.

Despite all these notable contributions, it is highly likely that the construct of alexithymia would not have had the current widespread recognition if it hadn’t been for the Toronto group.

In the 1990s, the Toronto group’s work allowed for a much more articulated specification of the construct of alexithymia. It is known that it originated in psychosomatic medicine, from the observation of patients suffering from chronic medical conditions, particularly from those that were long considered classic psychosomatic diseases (ulcers, rheumatoid arthritis, skin diseases, asthma).

Over the last 30 years, the definition of what constitutes a psychosomatic disease has profoundly changed, and it is now believed that there are no psychosomatic diseases, but rather psychosocial factors that carry different weight in certain individuals, regardless of the type of medical condition.

In fact, alexithymia cannot be considered a well-defined psychopathological syndrome like depression or abnormal illness behavior, but rather a personality trait not immediately correlated with any specific disorder.

Summarizing the research conducted up until then, Taylor and colleagues spoke in the early 1990s of alexithymia as a “potential paradigm for psychosomatic medicine,” mainly born from the theoretical shift in psychoanalysis from conflict to deficit.

At the end of the 1990s, the Toronto group published a book in which the perspective changed radically, opening the theoretical possibility of investigating alexithymia independently from the narrow niche of psychosomatic disorders.

In the 1997 book, alexithymia is conceived as the central and most easily identifiable element of a group of disorders, both medical, psychiatric, organic, and functional, which traditional nosography classifies under different homogeneous headings for research purposes.

Going beyond the descriptive symptomatic aspect and framing the disorders from the etiological point of view and the physiological processes, the hypothesis of the Canadian researchers is that the high comorbidity frequently found between discrete syndromes within DSM-IV Axis I and between Axis I and Axis II can be explained by the fact that they belong to the same overarching concept defined by affective regulation disorders.

Affective regulation does not simply indicate the control of emotions, but the ability to tolerate intense and/or prolonged negative affects (boredom, emptiness, anxiety, depression, anger) while balancing them with positive affects autonomously, that is, without resorting to external objects or behavioral acting (desires, suicides, substance use, eating disorders).

It therefore involves the activation of various interconnected systems of processing emotional responses in their biological (neuro-physiological and motor) and psychological (experiences and cognitive processing) components.

Moreover, affective regulation implies an intersubjective dimension because relationships with others provide interpersonal regulation of affects in a positive sense (e.g., inducing calm and relaxation) or negative (loss, aggression, tension).

Affective regulation disorders therefore refer to all those clinical conditions in which an individual is unable to use emotions as motivational systems and sources of information in relation to their own emotional states and their relationship with others.

Considering alexithymia from this perspective, the Toronto group’s research has focused on the development of assessment tools for the construct.

The TAS-20 (with its previous versions, namely the TAS with 26 items and the TAS-R) is undoubtedly the most well-known product of the Canadian researchers.

The Toronto Alexithymia Scale (TAS)

The Toronto group first sought to overcome the multiple limitations of the assessment tools that had been used up until that point to measure alexithymia, and then, consequently, to empirically test the validity of the construct.

Thanks to these goals and the different theoretical-methodological approaches of the three authors, the first version of the Toronto Alexithymia Scale (TAS) was created. It was composed of 41 items aimed at measuring five areas (Taylor, Bagby, Parker, 1997):

• Difficulty in describing feelings.
• Difficulty in distinguishing between feelings and physical sensations related to emotions.
• Lack of introspection.
• Presence of social conformity.
• Reduced memory of dreams.

After several studies, a factor analysis was applied to the scale, which allowed for reducing the items from 41 to 26, focusing on four dimensions:

• Difficulty in distinguishing and identifying sensations and feelings.
• Difficulty in describing feelings.
• Reduced daydreaming activity.
• Presence of an externally oriented thinking style.

Compared to the previous version, in the TAS with 26 items, “social conformity” was removed, as it was not consistently present in all subjects.

This second version of the TAS was then subjected to a cross-validation process on both clinical and non-clinical groups and several studies by Bagby, Taylor, and Doody (1985), which demonstrated not only convergent validity but also discriminant validity, with a high test-retest reliability of about five weeks, thus confirming the validity of the construct.

In further revisions of the scale, the dimension of “reduced memory of dreams” was also removed due to its negative correlation with the other dimensions, and the dimension related to “tendency for action rather than reflection” was eliminated.

Studies aimed at eliminating these limitations led to the creation of another version, the TAS-R with 23 items, focusing solely on two dimensions:

• The ability to distinguish between feelings, physical sensations, and emotions.
• The ability to describe one’s feelings to others.

Based on all these studies, the TAS-20 was then developed.

The Toronto Alexithymia Scale – 20 (TAS-20)

The Toronto Alexithymia Scale 20 (TAS-20) is the current version with 20 items. It is a self-report questionnaire in which the respondent is asked to provide an answer based on their level of agreement with each statement, using a 5-point Likert scale. Each point corresponds to a specific level of agreement (1 = strongly disagree, 2 = disagree somewhat, 3 = neither agree nor disagree, 4 = somewhat agree, 5 = strongly agree).

In this further version of the alexithymia assessment tool, the 20 items are related to three dimensions:

• Difficulty in identifying feelings (items: 1, 3, 6, 7, 9, 13, 14).
• Difficulty in communicating one’s feelings to others (items: 2, 4, 11, 12, 17).
• Presence of an externally oriented thinking style (items: 5, 8, 10, 15, 16, 18, 19, 20).

In addition to calculating the scores for these three dimensions, the total score obtained from all items is calculated.

The scoring method is as follows: for items 1, 2, 3, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 20, 1 point is awarded if the response is “1,” 2 points if “2,” and so on up to 5 points if the response is “5.”

For items 4, 5, 10, and 19, the scoring is reversed: 1 point for the response “5,” 2 points for “4,” and so on, up to 5 points for the response “1.”

Following these calculations, a score between a minimum of 20 and a maximum of 100 is obtained, thus categorizing respondents as:

• “Non-alexithymic” for scores below 51,
• “Borderline” for scores between 51 and 60,
• “Alexithymic” for scores equal to or above 61.

However, the third factor is less efficient, likely due to the reversed scoring process, and presents very low correlations compared to the other two dimensions and with the total scale.

Despite this, the TAS-20 has high internal consistency (Cronbach’s alpha = 0.81) and a good test-retest reliability over intervals of three months (r = 0.77), with the three factors being theoretically congruent with the construct.

For the TAS-20 to provide the most accurate information possible for patients, it must be administered in a specific setting that minimizes any distractions or influences, both from the environment and the clinician, and that allows for concentration throughout the task. No time limit is imposed. For this reason, it is preferable that the test be administered individually, or, if necessary, in small groups of two or three people seated far apart to limit any influences during the test.

Before administering the questionnaire, it is essential to minimize the information given to the patient about what they are going to study, simply stating that it is a test that “helps understand each person’s relationship with their emotions”.

The subject can be helped by reading the first item together and using it as an example to explain the response method based on their level of agreement, emphasizing that there are no “right” or “wrong” answers, only subjective responses.

After ensuring a correct understanding of how to use this tool, it is important to highlight that, being a self-administered test, it requires introspection and emotional communication skills, both at an intrapersonal level, which, as we remember, are the deficient aspects of alexithymic patients.

For this reason, it is crucial that the TAS never be used alone, but should be part of a multi-method approach that also uses other tools, such as the Rorschach projective test and the Thematic Apperception Test (TAT). It has been shown recently by Taylor et al. (1997) that non-alexithymic subjects, according to the TAS-20, use more complex and complete language in describing their feelings related to the TAT cards compared to alexithymic subjects, also allowing, as projective tests, insights into the representations of the Self, the object, and attachment schemas, aspects that are also deficient in alexithymia.

Toronto Structured Interview for Alexithymia (TSIA)

Despite the fact that the TAS-20 is still the most widely used tool for assessing alexithymia, it has limitations that cannot be overlooked.

The first of these is the issue of the test, which, being a self-administered questionnaire, raises doubts about its actual validity in measuring aspects of the alexithymia construct in individuals who may experience reasonable difficulty completing a test specifically related to their deficits in identifying and describing feelings.

The second issue is that, although the TAS-20 correlates with items related to operational thinking from the modified BIQ and with the Fantasy subscale of the NEO Personality Inventory (Bagby, Taylor, Parker, 1994), the test created by the Toronto group still has significant gaps in items that directly address this aspect, which is fundamental for the construct (Kooiman, Spinhoven, Trijsburg, 2002).

Based on the criticisms of these two limitations of the TAS-20, Bagby and colleagues decided in 2006 to create a structured interview: the Toronto Structured Interview for Alexithymia (TSIA).

This new approach allows clinicians and researchers to investigate and verify the responses given by the subject by asking for clarifications and examples to confirm or possibly disconfirm the answers, with the ultimate goal of understanding whether the initial assessment is specific and momentary for that context or if the characteristic being investigated shows a consistent and structured pattern in the individual’s life (Zimmermann, 1994).

However, the structured interview also has limitations. One of them is that it requires a moderate period of time and the scoring process—assigning scores to each question based on the subject’s responses—must be reliable and interpretable among different interviewers (Taylor et al., 2014).

In 2006, Bagby and colleagues adhered to the construct definition formulated by Nemiah, Freyberger, and Sifneos, which describes alexithymia as a difficulty in identifying and describing one’s feelings, coupled with the presence of an externally oriented thinking style that hinders imaginative and fantasy activities. Adhering to general test construction guidelines (Briggs, Cheek, Clark, Watson, Bearden, Sharma, Nunnally, Bernstein), they worked on formulating 60 items that would reflect the key aspects of the construct, with 15 items for each of the following: difficulty in identification, presence of operational thinking, and lack of imagination and fantasy.

These 60 items were partly retrieved from the TAS-20, the 26-item TAS, the modified BIQ, and an unpublished list used in the construction of the TAS and TAS-20, while other items were specifically created for this tool.

In the first phase of the interview construction, the TSIA was administered to a group of patients, and based on their responses, 5 items were eliminated as confusing or repetitive, and 12 items were considered irrelevant to the construct.

In the second phase, the remaining 43 items were administered in a hospital setting in Canada to two sample groups selected based on their response to an advertisement requesting volunteers for a study on personality and emotions.

The first group consisted of 136 adults with a mean age of 32.3 (SD = 9.78), drawn from the general population, excluding those with current or past diagnoses of mental disorders. The second group included 97 psychiatric patients with a mean age of 38.6 (SD = 12.3), excluding those with current or past diagnoses of psychotic disorders.

Another requirement was that participants should be able to read and speak English, and most of them had a high school diploma and belonged to the middle class.

The interview lasted one hour, and seven interviewers and one scorer participated. Prior to the interviews, they were required to study the interview guide and attend training sessions to familiarize themselves with the scoring and the formulation of the questions, especially the inquiry questions.

To select the final items, the distributions of the items were analyzed, eliminating those that were asymmetrical in both groups. Items that, according to all interviewers, were difficult for participants to understand or for coders to interpret were also removed. Finally, reliability statistics (Cronbach’s alpha) and principal component analysis were applied to further select the items.

After multiple factor analyses, a four-factor structure was ultimately chosen because it explained almost 50% of the total variance of the items (Netemeyer, Bearden, Sharma, 2004, and Taylor et al., 2014).

The TSIA is therefore a 24-question interview aimed at evaluating four dimensions of alexithymia:

• Difficulty identifying felt emotions, often found in confusion between different emotions or identifying feelings through the physical reactions associated with emotions. In this case, the interviewer must determine whether the subject is able to associate the feeling with the specific physical emotional reaction.
• Difficulty describing feelings to others, assessed based on the quality and quantity of the language used.
• Presence of an externally oriented thinking style, identifiable through descriptions of external details and situations while neglecting the internal experience within them.
• Absence of imaginative activity and fantasies.

These 24 items are arranged in such a way that each question is followed by another from a different dimension, in a cyclical and alternating manner until the end.

The items were formulated so that the interviewer could evaluate the responses based on a three-point continuum depending on the frequency or degree of presence of the specific characteristics investigated by each item.

In more detail, assigning a score of “0” means that the characteristic investigated is never present or, if it is, it is not typical for the subject.

A score of “1” is given when the characteristic is present only occasionally, and a score of “2” is given when it is significantly present, to the point where it can be considered a typical feature of the individual. This scoring method is designed so that the higher the score, the higher the level of alexithymia present.

In the interview manual, for each of the 23 main items, there are also inquiry questions aimed at learning more about what was analyzed, often requesting examples that can confirm the subject’s understanding or highlight inconsistencies.

An example to clarify the purpose of the inquiry might be as follows: item no. 14 asks: “When something good or bad happens to you, do you find it difficult to describe what you feel?” Whether the answer is “yes” or “no,” the interviewer will then ask for examples of situations, both good and bad, where the subject had difficulty describing their feelings or did not.

A score of “0” will be given if the subject shows no difficulty describing their feelings, “1” if some difficulty is shown, and “2” if significant difficulties are observed in the task.

If the subject answers “no” to the first item but later demonstrates an inconsistency in their response during the inquiry, the clinician will need to explore further with additional questions.

The scoring process should preferably be done during the interview itself, and only in cases of extreme necessity where it is unclear how to evaluate the response can it be done afterward, reassessing the criteria.

Furthermore, during the scoring process, it is important for the interviewer not to focus solely on the response given by the patient but also to consider whether the response is a result of an alexithymic process or a defense mechanism. Defense mechanisms such as inhibition, repression, and avoidance can easily be confused with alexithymic mechanisms, which involve deficits in emotional mental representations.

Therefore, it is essential for the interviewer to question whether the response is genuinely the result of a cognitive processing deficit or the outcome of a psychological defense mechanism.

Before administering the interview, it is crucial for the clinician to emphasize that there are no “right” or “wrong” answers, only subjective responses, and that the questions asked will relate to how they see themselves and how others might see them (Taylor et al., 2014).

The Toronto group has played a leading role in contemporary psychological sciences.

The fundamental importance lies in the fact that the Canadian researchers succeeded in emancipating the “local” construct of alexithymia, which was originally confined to the field of psychosomatic medicine, and turning it into the cornerstone of a broader explanation of clinical phenomena related to affective disorganization.

This has allowed researchers worldwide to investigate the construct itself, detached from the traditional association with a class of disorders (so-called psychosomatic diseases), while also shedding light on a wide range of clinical, somatic, and psychopathological phenomena characterized by emotional dysregulation.

Thanks to this paradigm shift, research on alexithymia has yielded new and interesting results over the past 10-15 years.

The Toronto group’s advantage over the pioneers of alexithymia research is likely due to their open scientific mindset. They have not only integrated multispecialty expertise but have organized their work around a progressive research protocol that allows for the continuous interaction of theory-building and field (clinical, empirical, and experimental) validation, thus avoiding the risks of excessive abstraction on one hand and the aggregation of empirical data without explanatory frameworks on the other.

This is confirmed by the network of research groups from different geographic regions and disciplinary fields that has formed around the construct of alexithymia, with the Toronto group as its “natural” reference center. This is demonstrated by the many co-authored works published in the last decade and the numerous international congresses on the subject.

Conclusions

The objective of this paper is to highlight the relationship between the mind and body, especially in psychological manifestations such as alexithymia, where the concept of emotion is strongly implicated. Therefore, in the first part of this paper, an attempt was made to define the concept of “emotion,” but it was observed that the field of emotional sciences is still in the process of development, and it is currently difficult and limiting to assign a singular and specific definition to the term. The search for meaning and the description of the characteristics and functioning of emotional states vary depending on the general theoretical perspective of the individual, meaning how their mental functioning is conceptualized, how physiological activation and bodily changes involved in psychic processes are understood, and how their relationship with the relational and cultural environment is explained, in order to improve and enrich emotional experiences through social sharing. Currently, in the scientific community, despite not having reached a universally agreed-upon definition of “emotion,” there is near unanimous consensus that emotions are characterized by both psychic and somatic elements. The earliest scientific contributions highlighting the relationship between mind and body in emotional states can be traced back to James (1884) with his somatic theory of emotions, which was later taken up and empirically confirmed by Damasio’s somatic marker theory (1994). Considering emotions as the quintessential somatopsychic and psychosomatic element helps emphasize the close correlation between mind and body, leading to a reflection on how the psychic and bodily elements of an emotional state are interconnected and the consequences of poor or incorrect communication between the systems of the body. Psychosomatics is a field of study and research that, starting from Freud’s early models of hysterical conversion, identified the cause of certain forms of organic pathology in the influence of individual mental suffering, typically conflictual, which manifests in the body.

Alexithymia, which literally means “lack of words for emotions,” is a relatively recent construct (1970), and as highlighted by Taylor and colleagues (Toronto Group 2000, 2013), it refers to a personality dimension characterized by a cognitive-experiential deficit in the cognitive evaluation of emotional experience. It is considered a risk factor for various physical and mental pathologies, particularly those related to emotional dysregulation disorders. We owe the development and measurement of alexithymia to the Toronto Group, which led to the creation of the TAS-20. The Toronto Alexithymia Scale is a practical and effective tool for evaluating such an important dimension of psychological functioning and is useful in both experimental and clinical settings.

The alexithymic deficit affects the correct awareness and regulation of one’s emotional reactions according to the context. Therefore, alexithymia is a construct worth noting because the deficit it represents concerns a mental dysfunction that impacts the overall evaluation of emotional experience, affecting both the bodily aspect and the relational dimension of the individual.

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1. Dott. ssa Marzia Capece, Psychologist expert in legal psychology, penitentiary and clinical criminology. ↑
2. Dott. ssa Carmen Ferraioli, expert in human sciences, law and criminology. ↑