Scholarly article on topic 'Alexithymia in schizophrenia: Associations with neurocognition and emotional distress'

Alexithymia in schizophrenia: Associations with neurocognition and emotional distress Academic research paper on "Psychology"

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Psychiatry Research
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Abstract of research paper on Psychology, author of scientific article — Rebecca Fogley, Debbie Warman, Paul H. Lysaker

Abstract While alexithymia, or difficulties identifying and describing affect, has been commonly observed in schizophrenia, little is known about its causes and correlates. To test the hypothesis that deficits in emotion identification and expression result from, or are at least related to, deficits in neurocognition and affective symptoms, we assessed alexithymia using the Toronto Alexithymia Scale (TAS-20), symptoms using the Positive and Negative Syndrome Scale (PANSS), and neurocognition using the MATRICS battery among 65 adults with schizophrenia spectrum disorders in a non-acute phase of illness. Partial correlations controlling for the effects of social desirability revealed that difficulty identifying feelings and externally oriented thinking were linked with greater levels of neurocognitive deficits, while difficulty describing feelings was related to heightened levels of emotional distress. To explore whether neurocognition and affective symptoms were uniquely related to alexithymia, a multiple regression was conducted in which neurocognitive scores and affective symptoms were allowed to enter to predict overall levels of alexithymia after controlling for social desirability. Results revealed both processing speed and anxiety uniquely contributed to the prediction of the total score on the TAS-20. Results suggest that dysfunctions in both cognitive and affective processes may be related to alexithymia in schizophrenia independently of one another.

Academic research paper on topic "Alexithymia in schizophrenia: Associations with neurocognition and emotional distress"

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Alexithymia in schizophrenia: Associations with neurocognition and emotional distress

Rebecca Fogleya, Debbie Warmana, Paul H. Lysakerb,c'*

a University of Indianapolis, School of Psychological Sciences, Indianapolis, IN, USA b Roudebush VA Medical Center, Indianapolis, IN, USA c Indiana University School of Medicine, Indianapolis, IN, USA


While alexithymia, or difficulties identifying and describing affect, has been commonly observed in schizophrenia, little is known about its causes and correlates. To test the hypothesis that deficits in emotion identification and expression result from, or are at least related to, deficits in neurocognition and affective symptoms, we assessed alexithymia using the Toronto Alexithymia Scale (TAS-20), symptoms using the Positive and Negative Syndrome Scale (PANSS), and neurocognition using the MATRICS battery among 65 adults with schizophrenia spectrum disorders in a non-acute phase of illness. Partial correlations controlling for the effects of social desirability revealed that difficulty identifying feelings and externally oriented thinking were linked with greater levels of neurocognitive deficits, while difficulty describing feelings was related to heightened levels of emotional distress. To explore whether neurocognition and affective symptoms were uniquely related to alexithymia, a multiple regression was conducted in which neurocognitive scores and affective symptoms were allowed to enter to predict overall levels of alexithymia after controlling for social desirability. Results revealed both processing speed and anxiety uniquely contributed to the prediction of the total score on the TAS-20. Results suggest that dysfunctions in both cognitive and affective processes may be related to alexithymia in schizophrenia independently of one another.

Published by Elsevier Ireland Ltd.

Article history: Received 24 December 2013 Received in revised form 18 February 2014 Accepted 7 April 2014







Social cognition MATRICS

1. Introduction

Alexithymia refers to a range of interrelated difficulties, including (a) identifying feelings and distinguishing between feelings and bodily sensations of emotional arousal; (b) describing feelings to others; (c) constricted imaginal processes; and (d) a stimulus-bound, externally orientated cognitive style (Taylor et al., 1997). In contrast to constructs such as mentalization and metacognition, alexithymia focuses specifically on awareness and expression of one's own emotions. Heightened levels of alexithymia in a number of different schizophrenia samples (Stanghellini and Ricca, 1995; Cedro et al., 2001; Todarello et al., 2005; Van't Wout et al., 2007; van der Meer et al., 2009; Koelkebeck et al., 2010; Kubota et al., 2011) have led several authors to hypothesize that alexithymia may be a vulnerability factor for the development of schizophrenia (Van't Wout et al., 2007; van der Meer et al., 2009), and more specifically may be an underlying cause of social dysfunction (Van't Wout et al., 2007).

* Corresponding author at: Roudebush VA Med Center (116H), 1481 West 10th Street, Indianapolis, IN 46202, USA. Tel.: +1 317 554 0000. E-mail address: (P.H. Lysaker). 0165-1781/Published by Elsevier Ireland Ltd.

A range of studies has sought to better understand the presence of alexithymia among persons with schizophrenia by examining its links to other features of illness, particularly symptoms. Stanghellini and Ricca (1995) found that patients with a predominantly non-paranoid, negative symptom presentation were significantly more likely to be identified as alexithymic compared to those presenting primarily with paranoia, whereas Van't Wout et al. (2007) found that negative symptoms were linked with deficits in identifying feelings only. These authors also noted greater alexithymia among male patients and among male first-degree relatives compared to control subjects. Examining alexithymia and positive symptoms, Cedro et al. (2001) found alex-ithymia to be more prevalent in persons with the paranoid subtype of schizophrenia compared to matched healthy controls. Other findings challenge the link between alexithymia and positive and negative symptoms. For instance, one study found that negative symptoms abated during the course of one year while alexithymia remained stable (Todarello et al., 2005). This study also observed no significant associations between alexithymia and global psychopathology, positive symptoms, or depression. Similar to others, van der Meer et al. (2009) again found that persons with schizophrenia experienced more difficulties identifying their feelings than others without psychosis, and noted that alexithymia

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was positively correlated with depression. Gender differences did not emerge as significant in this study. As a whole, this body of work is equivocal and at best raises the possibility of a very complicated relationship between alexithymia and symptoms.

Research has to our knowledge, however, yet to examine neurocognition and alexithymia simultaneously in schizophrenia. Neurocognitive deficits have been commonly observed in schizophrenia (Saykin et al., 1991), and there are several reasons to think that they may be linked to alexithymia. Neurobiological research suggests that persons with alexithymia have impaired interhemispheric communication and may have brain structures or functional circuits that are dysfunctional or deficient (Larsen et al., 2003; Taylor and Bagby, 2004; Wingbermuhle et al., 2012). Lane (2008) also proposes a neural model of alexithymia that has some empirical support. In a nonclinical population, higher levels of alexithymia have been associated with poorer neurocognitive test performance, specifically poorer memory and nonverbal intelligence (Onor et al., 2010). Among asymptomatic individuals with HIV, greater alexithymia has been significantly related to poorer attention, working memory, spatial reasoning, and visuos-patial organization (Bogdanova et al., 2010). Research on synthetic metacognitive capacity, or the ability to form complex representations of oneself and others, has found that unaware-ness of one's emotions in schizophrenia is related to poorer verbal memory, processing speed, and executive functioning (Lysaker et al., 2011b), and those who lack the ability to distinguish their own thoughts and feelings tend to have poorer working memory (Lysaker et al., 2007). An improved understanding of the links between alexithymia and neurocognition seems essential if we are to better understand how alexithymia may develop and how it may be addressed in treatment, which appears indicated given its associations with functional impairments (Vanheule et al., 2010) and poor psychotherapeutic outcomes (ogrodniczuk et al., 2011).

To address this issue the current study has examined the relationship of concurrent assessments of alexithymia, neurocog-nition, and symptoms among a sample of persons with schizophrenia spectrum disorders. Our primary prediction was that greater levels of alexithymia would be related to poorer neuro-cognition. Of note, we assessed a range of different neurocognitive domains and considered the examination of each specific domain to be exploratory in nature. In regard to symptoms, we predicted that alexithymia would be positively and significantly related to depression and anxiety given repeated findings that alexithymia is related to depressive and anxiety disorders (e.g., Parker et al., 1993; Honkalampi et al., 1999; Marchesi et al., 2000, 2005; Saarijarvi et al., 2001; Leweke et al., 2011). We did not anticipate that alexithymia would be significantly related to positive and negative symptoms given the equivocal findings of previous studies.

Of note, to assess alexithymia we used the Toronto Alexithymia Scale-20 (TAS-20; Bagby et al., 1994a). While this is the most utilized measure of alexithymia (Lumley, 2000; Bagby et al., 2006), it is possible that scores would be biased by socially desirable responding given that the TAS-20 is a self-report measure. Helmes et al. (2008), for instance, found that among three samples of undergraduate students, alexithymia as measured by the TAS-20 was significantly and negatively related to socially desirable responding. In particular, lower levels of alexithymia were significantly related to higher scores on a measure of social desirability that taps unintentional, or unconscious, attempts to portray oneself in a positive light. Given these findings and general concerns about self-report, we included a measure of social desirability to be used as a covariate in other analyses if necessary. Finding Helmes et al. (2008) distinction between intentional and unintentional socially desirable responding interesting, we utilized

a two-factor model of the Marlowe-Crowne Social Desirability Scale (MCSDS; Crowne and Marlowe, I960) that allowed for similar distinctions.

2. Methods

2.1. Participants

Participants were 65 adults with diagnoses of schizophrenia (n—42) or schizoaffective disorder (n—23), as confirmed by the Structured Clinical Interview for DSM-IV (SCID; Spitzer et al., 1994). Participants were enrolled as part of a larger study on cognitive-behavioral therapy and work outcomes for persons with schizophrenia spectrum disorders. All participants were recruited from a local Veterans Affairs medical center and were in a post-acute phase of illness as defined by no hospitalizations and no changes in psychotropic medication or housing within 30 days prior to enrollment. Other exclusion criteria included active substance dependence, history of traumatic brain injury, and mental retardation, which were determined through chart review and the SCID. On average (mean + -standard deviation), participants were 50.54 + 10.75 years old, had 12.74 + 2.31 years of education, and had 5.02 + 4.68 lifetime psychiatric hospitalizations, with the first occurring at age 29.66 + 12.92. Thirty-six participants identified as African American, 28 as Caucasian, and one as Latino. Sixty-one were male, and four were female.

2.2. Instruments

2.2.1. The Toronto Alexithymia Scale

The Toronto Alexithymia Scale-20 (TAS-20; Bagby et al., 1994a) is a 20-item self-report measure of alexithymia. Items are rated using a five-point Likert scale, with participants indicating level of agreement with statements that assess both the affective and cognitive elements of the alexithymia construct. Total scores range from 20 to 100, with higher scores indicating greater degree of alexithymia. Though the present study analyzed alexithymia as a dimensional construct, it has been suggested that scores exceeding 60 are indicative of clinically significant alexithymia (Taylor and Taylor, 1997). In addition to a total score, the TAS-20 yields three factor scores: difficulty identifying feelings, difficulty describing feelings, and externally oriented thinking. Evidence of acceptable internal consistency, test-retest reliability, and construct, concurrent, and convergent validity has been reported (Bagby et al., 1994a, 1994b). For this study sample, acceptable internal consistency was found using Cronbach's alpha (a—0.75). Research suggests the TAS-20 is appropriate for use with persons from a variety of backgrounds (Parker et al., 2003).

2.2.2. The Positive and Negative Syndrome Scale

The Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987) is a 30-item rating scale scored by trained research staff following chart-review and a semi-structured interview. Items are rated on a scale ranging from one to seven, with higher scores reflective of greater symptom severity. A series of studies summarized by Kay et al. (1987) supports the construct, convergent, and discriminant validity of the PANSS. For this study, we utilized three of five factor-analytically derived components: positive symptoms, negative symptoms, and emotional discomfort. The emotional discomfort component contains items that assess anxiety, depressed mood, guilt, and active social avoidance. Good to excellent intraclass correlations for each scale and most items suggest reliable symptom assessment using the factor components (Bell et al., 1994). For this study, assessment of inter-rater reliability was found to be high to excellent with intraclass correlations for blind raters observing the same interview ranging from 0.84 to 0.93. To reduce the overall number of correlations produced in this study, the cognitive and hostility components were not examined given a lack of predictions regarding the relationships between these factors and alexithymia.

2.2.3. The Measurement and Treatment Research to Improve Cognition in Schizophrenia

The Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS; Nuechterlein et al., 2008) is a widely used standard battery for measuring cognition in schizophrenia. It consists of ten tests that assess seven cognitive domains, including processing speed, attention/vigilance, verbal and nonverbal working memory, verbal learning, visual learning, reasoning and problem solving, and social cognition. Individual tests were selected for their high reliability and validity, and the measure as a whole is also reliable and valid for generating a composite score for cognitive functioning.

2.2.4. The Marlowe-Crowne Social Desirability Scale

The Marlowe-Crowne Social Desirability Scale (MCSDS; Crowne and Marlowe, 1960) is a 33-item self-report measure that prompts participants to indicate if questions about their experiences are true or false. Items include culturally

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sanctioned behaviors that are nonetheless unlikely to occur. Higher scores suggest a need to obtain approval by responding in what is perceived as a culturally approved manner. Ventimiglia and MacDonald (2012) proposed a two-factor model of the MCSDS that includes impression management (IM) and self-deception (SD). IM reflects efforts to knowingly respond in a manner that creates a favorable self-representation for others, whereas SD reflects a socially naive self-image that does not involve deliberate misrepresentation of one's self. Ventimiglia and MacDonald (2012) reported an adequate Cronbach's alpha for IM (a—0.65) and a weak reliability coefficient for SD (a—0.51). In another sample, items from IM yielded a satisfactory reliability coefficient (a—0.85) and items from SD demonstrated an adequate Cronbach's alpha (a—0.60) (Guerrero and Lysaker, 2013).

23. Procedures

All procedures were approved by the appropriate research review committees. Following written informed consent, the SCID was administered by a clinical psychologist in order to confirm diagnoses and assess exclusion criteria. Participants then completed a demographic questionnaire and an assessment battery that included the measures for this study. Measures were administered in a random order by a trained research assistant who held at minimum a Bachelor's degree. PANSS ratings were performed blind to responses on other measures. Though participants underwent additional procedures as part of the larger study on cognitive-behavioral therapy, all data utilized for the present study was derived from the baseline assessment prior to any intervention.

2.4. Analyses

Analyses were planned in four stages. First, we planned to assess whether demographic variables and response style on the MCSDS were significantly related to TAS-20 scores. If so, we planned to use these variables as covariates in subsequent analyses. Second, we planned to examine whether TAS-20 scores were significantly related to MATRICS and PANSS component scores. Third, we planned to determine if TAS-20 scores were significantly related to specific PANSS symptoms if the parent PANSS component score was significantly related to alexithymia. Given the number of planned correlations, we reduced alpha to 0.025 and chose to utilize two-tailed tests despite unidirectional hypotheses. Fourth, if there was evidence of significant relationships between alexithymia and response style, neurocognition, and symptoms, we planned to conduct multiple regressions to determine the extent to which these variables predicted alexithymia scores.

3. Results

Means and standard deviations for all key variables are presented in Table 1. Univariate correlations revealed that age was unrelated to TAS-20 factor scores and total score (r=0.13, p=0.29;

Table 1

Descriptive statistics for response style, alexithymia, symptoms, and neurocognition (N=65).

Instrument Factor Mean Standard deviation

MCSDS Impression management 2.88 2.05

Self-deception 7.72 1.31

TAS-20 Difficulty identifying feelings 20.43 б.20

Difficulty describing feelings 15.бб 3.7б

Externally oriented thinking 22.17 3.49

Total 58.2б 11.43

MATRICS Processing speed 31.54 10.4б

Attention 35.15 9.72

Working memory 34.05 10.42

Verbal memory 35.34 8.29

Visual memory 33.38 10.44

Abstract reasoning 37.38 б.39

Social cognition 35.71 11.87

Composite 24.89 10.24

PANSS Positive symptoms 18.37 5.04

Negative symptoms 19.85 5.08

Emotional discomfort

Anxiety 3.20 1.20

Depression 3.57 1.б1

Guilt 1.8б 1.28

Active avoidance 3.52 1.25

r=0.04, p=0.75; r=0.17, p=0.17; r=0.14, p=0.27), as was education (r =-0.11, p = 0.42; r =-0.14, p = 0.27; r =-0.14, p = 0.27; r=0.15, p=0.24). T tests revealed that TAS-20 total scores and three subscales did not differ between men and women (t=0.77, p = 0.44; t = -0.50, p = 0.62; t=-1.29, p = 0.20; t=0.14, p = 0.89) or between participants with schizophrenia or schizoaffective disorder (t = 1.52, p = 0.14; t=0.98, p = 0.33; t = 0.82, p = 0.42; t = 1.14, p=0.17). The impression management factor from the MCSDS was positively and significantly related to TAS-20 total (r = 0.53, p=0.0001) and all TAS-20 factor scores (r=0.50, p=0.0001; r=0.47, p=0.0001; r= .35, p=0.005). The self-deception factor from the MCSDS was positively and significantly related to TAS-20 Factor 1 (r = 0.38, p=0.002), Factor 2 (r=0.27, p=0.03) and TAS-20 total (r = 0.35, p=0.004). No significant links were found between self-deception and the TAS-20 Factor 3 score (r=0.16, p=0.19). Given these findings, impression management (i.e., deliberate favorable self-representation) was utilized as a covariate in subsequent analyses.

Next, a series of Pearson correlations was utilized to test hypotheses about the potential relationships between alexithymia and symptoms and neurocognition. While controlling for impression management, a number of significant relationships emerged that were generally consistent with our predictions. These findings are displayed in Table 2. Of note, both neurocognitive performance and select symptoms were significantly related to difficulty identifying feelings and overall level of alexithymia. Examining the Emotional Discomfort component of the PANSS in more detail revealed significant and positive relationships between anxiety and difficulty identifying feelings (r=0.36, p=0.002), depression and difficulty identifying feelings (r= 0.46, p= 0.000), and no significant relationships with either guilt or active avoidance with difficulty identifying feelings (r = -0.04, p=0.73; r = 0.22, p=0.08, respectively).

Finally, to determine whether significant correlates were uniquely predictive of difficulty identifying feelings and total level of alexithymia, two stepwise multiple regressions were conducted. In these analyses impression management was always entered in the first step in order to control for potential response bias. As summarized in Table 3, these analyses revealed that greater difficulty identifying feelings was predicted by greater efforts at impression management, poorer working memory, more severe

Table 2

Correlations of alexithymia and symptoms and neurocognition while controlling for impression management (N= б5).

TAS-20 Factor 1 TAS-20 Factor 2 TAS-20 Factor 3 TAS-20 Total

PANSS components

Positive symptoms - 0.19 0.07 - 0.1б 0.08

Negative symptoms - 0.0б 0.10 -0.03 - 0.01

Emotional discomfort 0.31" 0.32« 0.05 0.30"


Processing speed - 0.34nn - 0.14 - 0.42nnn - 0.38nn

Attention - 0.12 - 0.0б - 0.32nn - 0.20

Working memory - 0.39"°" - 0.11 - 0.29" - 0.35nn

Verbal memory - 0.34nn -0.02 - 0.1б - 0.25

Visual memory - 0.34nn - 0.12 - 0.28" - 0.32nn

Abstract reasoning - 0.32nn -0.03 -0.23 - 0.27

Social cognition -0.21 -0.05 - 0.33** - 0.24

Composite — 0.44nnn - 0.12 - 0.4б*** - 0.44nnn

TAS-20 Factor 1 = difficulty identifying feelings; TAS-20 Factor 2=difficulty describing feelings; TAS-20 Factor 3=externally oriented thinking * p<0.025. ** p<0.01. *** p < 0.001.

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Table 3

Stepwise multiple regressions predicting alexithymia from variables found to be significant in univariate correlations.

Significant Predictors R2 Total R2 (d.f.) F

TAS-20 Factor 1 Impression management 0.25 0.25 (4,60) 14.62"

Working memory 0.11 0.36

Anxiety 0.08 0.44

Verbal memory 0.05 0.49

TAS-20 Total Impression management 0.28 0.28 (3,61) 17.14"

Processing speed 0.10 0.38

Anxiety 0.08 0.46

* p < 0.001.

anxiety, and poorer verbal memory. Together, these variables accounted for 49% of the variance in TAS-20 Factor 1 scores. Regarding overall level of alexithymia, analyses revealed that higher alexithymia was predicted by greater efforts at impression management, poorer processing speed, and more severe anxiety, accounting for 46% of the variance in TAS-20 total scores.

Finally, to explore the relationship among cognitive and affective variables from the vantage point of general relationship, we conducted two standard regressions, this time entering both the MATRICS total score and PANSS anxiety score to first predict the TAS-20 Factor 1 and then the TAS-20 total. Both regressions were significant (F(4,62) — 8.06, p — 0.001; F(4,62) — 7.78, p — 0.001, respectively). The beta weights for the MATRICS composite score were -0.28 (p—0.02) and -0.27 (p—0.02) respectively. The beta weights for the PANSS anxiety score were 0.35 (p—0.003) and 0.35 (p—0.003).

4. Discussion

In this study we examined the potential relationships between alexithymia and neurocognition and symptoms among persons with schizophrenia spectrum disorders, controlling for impression management, which is a response style which might affect the self-report of alexithymia. As predicted, greater levels of alexithy-mia were generally significantly associated with poorer neurocog-nition, and more specifically, difficulty identifying feelings and externally oriented thinking were linked with a broad range of neurocognitive impairments. While we did not find significant links between alexithymia and positive or negative symptoms, consistent with our hypothesis, greater emotional discomfort was associated with overall level of alexithymia and more specifically with difficulty identifying and describing feelings. Overall, the link between emotional discomfort and alexithymia appears to be accounted for by underlying associations between both anxiety and depression and alexithymia. When we conducted multiple regression analyses to examine whether the links of emotional distress and neurocognitive deficits with alexithymia were independent of one another, we found that after controlling for impression management, working memory, anxiety, and verbal memory were each significant predictors of difficulty identifying feelings, and processing speed and anxiety were both significant predictors of overall level of alexithymia.

While causal inferences cannot be drawn from this cross sectional data, our results raise several possibilities that can be the subject of future research. First, it may be that a certain level of neurocognitive competence is necessary to engage in self-reflective activities, such as the ability to reflect on one's emotions. Based on our findings, for example, it may be necessary for persons to be able to hold and manipulate information in memory before they can pinpoint their affective states. This possibility is consistent with the broader literature on the interactions between

neurocognition and metacognition (Lysaker et al., 2007, 2010, 2011b), Theory of Mind (Pickup, 2008), and related literature suggesting alexithymia entails a deficit in thinking about one's internal states (Dimaggio et al., 2009). Second, while neurocogni-tive capacities may be needed to identify feelings, the ability to express feelings may require the absence of emotional distress. One possibility is that anxiety or depression dampens the ability or motivation to express feelings. Alternatively, it could be that disturbances in the ability to express feelings are central and result in distress. For instance, it is possible that struggling to translate physiological sensations into an emotion that can be named could engender a diffuse distressed emotional state like anxiety or depression. Both possibilities are consistent with recent findings linking first episode major depression with decrements in self-reflectivity (Ladegaard et al., in press). It is also possible that observed relationships were the product of other factors not measured here, such as trauma.

At the very least these findings suggest that alexithymia in schizophrenia is a complex phenomenon with distinguishable connections with disturbances in both affect and cognition. Findings also support the intriguing assertion that perceiving and expressing one's own emotions are sufficiently distinct processes, with the former in schizophrenia tied to both neurocognition and distress, and the second tied to distress alone. Beyond that, having an externalizing orientation shares some of the same associations as identifying feelings with neurocognition but not with affect.

Another finding deserving comment concerns the fact that in our sample greater efforts to present oneself in a favorable light were linked with lesser reports of alexithymia. As the most utilized measure of alexithymia (Lumley, 2000; Bagby et al., 2006), the TAS-20 has been commonly used without controlling for biases that may arise due to self-report, perhaps because the measure was reportedly designed to limit such influences (Bagby et al., 1994a). While phenomenon such as insight may not be linked with response style (cf. Bell et al., 2007), it may be that future work needs to statistically control for such influences or utilize alternate measures. Though TAS-20 scores are significantly related to assessments of alexithymia that use clinician interviews, Meganck et al. (2011) assert that interviews provide a better gauge of alexithymia. Similarly, Lumley et al. (2005) found that self-report measures of alexithymia converge with interview ratings, collateral reports, and performance-based assessments, though only to a modest degree (r=0.20-0.30), thus highlighting the utility of using multi-method assessment or eliminating the use of self-report measures. Of note, the convergent validity of these measures was not assessed using samples of persons with schizophrenia. As such, future research may examine convergence of self-report and other measures of alexithymia within this population, and consider using alternate measures, such as the Observer Alexithymia Scale (OAS; Haviland et al., 2000), the modified Beth Israel Hospital Psychosomatic Questionnaire (mBlQ; Taylor et al., 2000), or the Toronto Structured Interview for Alexithymia (TSIA; Bagby et al., 2006).

Of note, this study has several limitations. First, this study utilized a small sample of participants who were predominantly male and middle-aged given the research setting (Veterans Affairs medical center). Further, the sample was largely comprised of persons who had experienced psychosis for long periods of time, had been hospitalized on numerous occasions, and were at least somewhat engaged in a treatment setting. As such, it is unclear to what extent results from the present study apply to younger adults experiencing psychosis, persons experiencing a first-episode, and those who decline treatment. Given findings that gender may affect metacognition (Abu-Akel and Bo, 2013), more work is needed examining this phenomenon in samples with a greater representation of women. Affective symptoms were furthermore

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assessed with single indices, which may be less sensitive than self-reports which contain multiple items. Future research could benefit from utilizing larger and more diverse samples in order to increase confidence in, and generalizability of, the results.

With replication, findings may have important implications for clinical work. We found that persons with more significant neurocognitive impairments were more likely to have more severe alexithymia, raising the possibility that for such persons, certain treatments may be complicated by both neurocognitive compromise and self-reflective deficits. To be specific, difficulties with memory and identifying feelings could pose challenges for cognitive-behavioral therapy for schizophrenia, which has been found to be efficacious, though not for all persons with the disorder (Rector and Beck, 2012). With less developed or lost abilities to remember and process specific events and thoughts, and identify corresponding emotions, other treatments may be necessary in order to promote recovery from schizophrenia. Further, if metacognitive deficits such as alexithymia are vulnerability factors to developing psychosis, as hypothesized by several researchers (e.g., Brüne, 2003; Van't Wout et al., 2007; van der Meer et al., 2009; Dimaggio and Lysaker, 2010), alternate treatment approaches also may hold promise for preventing the emergence of aspects of illness such as symptoms and functional impairment. As such, it may be useful to consider and further develop interventions that target alexithymia and neurocognitive impairments that may make self-reflection difficult. Integrative psychotherapy that targets metacognition could assist persons to develop these capacities (Hasson-Ohayon, 2012; Lysaker et al., 2010, 2011a), as has been demonstrated in several studies (e.g., Brent, 2009; Buck & Lysaker, 2009; Salvatore et al., 2012), and cognitive remediation (Bell et al., 2008) could provide the groundwork necessary for metacognitively focused psychotherapy to be successful.


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