Low Alexithymia Research Articles

Language or rating scales based classifications of emotions: computational analysis of language and alexithymia

Rating scales are the dominating tool for the quantitative assessment of mental health. They are often believed to have a higher validity than language-based responses, which are the natural way of communicating mental states. Furthermore, it is unclear how difficulties articulating emotions—alexithymia—affect the accuracy of language-based communication of emotions. We investigated whether narratives describing emotional states are more accurately classified by questions-based computational analysis of language (QCLA) compared to commonly used rating scales. Additionally, we examined how this is affected by alexithymia. In Phase 1, participants (N = 348) generated narratives describing events related to depression, anxiety, satisfaction, and harmony. In Phase 2, another set of participants summarized the emotions described in the narratives of Phase 1 in five descriptive words and rating scales (PHQ-9, GAD-7, SWLS, and HILS). The words were quantified with a natural language processing model (i.e., LSA) and classified with machine learning (i.e., multinomial regression). The results showed that the language-based responses can be more accurate in classifying the emotional states compared to the rating scales. The degree of alexithymia did not influence the correctness of classification based on words or rating scales, suggesting that QCLA is not sensitive to alexithymia. However, narratives generated by people with high alexithymia were more difficult to classify than those generated by people with low alexithymia. These results suggest that the assessment of mental health may be improved by language-based responses analyzed by computational methods compared to currently used rating scales.

Literally or prosodically? Recognising emotional discourse in alexithymia

ABSTRACT Alexithymia is characterised by difficulties in identifying, recognising, and describing emotions. We studied alexithymia in the context of speech comprehension, specifically investigating the incongruent condition between prosody and the literal meaning of words in emotion-based discourse. In two experiments, participants were categorised as having high or low alexithymia scores based on the TAS-20 scale and listened to three-sentence narratives where the emotional prosody of a key phrase or a keyword was congruent or incongruent with its literal meaning. The incongruent condition resulted in slower reaction times and lower accuracy in recognition of emotions. This incongruence effect was also evident for individuals with high alexithymia, except for anger. They recognised anger as accurately in both congruent and incongruent conditions. Contrary to our hypothesis, however, individuals with high alexithymia did not show an overall difference in emotion recognition compared to the low alexithymia group. These findings highlight the nuanced relationship between emotional prosody and literal meaning, offering insights into how individuals with varying levels of alexithymia process emotional discourse. Understanding these dynamics has implications for both cognitive research and clinical practice, providing valuable perspectives on speech comprehension, especially in situations involving incongruence between prosody and word meaning.

Alexithymia modulates emotion concept activation during facial expression processing.

Alexithymia is characterized by difficulties in emotional information processing. However, the underlying reasons for emotional processing deficits in alexithymia are not fully understood. The present study aimed to investigate the mechanism underlying emotional deficits in alexithymia. Using the Toronto Alexithymia Scale-20, we recruited college students with high alexithymia (n = 24) or low alexithymia (n = 24) in this study. Participants judged the emotional consistency of facial expressions and contextual sentences while recording their event-related potentials. Behaviorally, the high alexithymia group showed longer response times versus the low alexithymia group in processing facial expressions. The event-related potential results showed that the high alexithymia group had more negative-going N400 amplitudes compared with the low alexithymia group in the incongruent condition. More negative N400 amplitudes are also associated with slower responses to facial expressions. Furthermore, machine learning analyses based on N400 amplitudes could distinguish the high alexithymia group from the low alexithymia group in the incongruent condition. Overall, these findings suggest worse facial emotion perception for the high alexithymia group, potentially due to difficulty in spontaneously activating emotion concepts. Our findings have important implications for the affective science and clinical intervention of alexithymia-related affective disorders.

Neural correlates of perceptual switching and their association with empathy and alexithymia in individuals with and without autism spectrum disorder

Individuals with autism spectrum disorder (ASD) often show limited empathy (poor recognition of others’ emotions) and high alexithymia (poor recognition of own emotions and external thinking), which can negatively impact their social functioning. Previous experimental studies suggest that alterations in cognitive flexibility play key roles in the development of these characteristics in ASD. However, the underlying neural mechanisms that link cognitive flexibility and empathy/alexithymia are still largely unknown. In this study, we examined the neural correlates of cognitive flexibility via functional magnetic resonance imaging during perceptual task-switching in typical development (TD) adults and adults with ASD. We also investigated associations between regional neural activity and psychometric empathy and alexithymia scores among these populations. In the TD group, stronger activation of the left middle frontal gyrus was associated with better perceptual switching and greater empathic concern. Among individuals with ASD, stronger activation of the left inferior frontal gyrus was associated with better perceptual switching, greater empathy, and lower alexithymia. These findings will contribute to develop a better understanding of social cognition, and could be informative for the development of new ASD therapies.

A case for emojis, more or less: An analysis of word and emoji expressivity in text messaging for high and low alexithymia levels

The impact of alexithymia on verbal and non-verbal expressivity was investigated in one of the most prevalent mediums for present-day human interacting, smartphone text messaging. The variety of words and emojis used to express negative, neutral and positive feelings was compared between people with higher and lower levels of alexithymia measured by the Perth Alexithymia Questionnaire, controlling for covariates anxiety and depression. Verbal expressivity was not impacted by higher levels of alexithymia, for total scores nor by subscale. Non-verbal expressivity for high-level alexithymia showed differences in variety of emoji on two subscales: compared to low-level alexithymia, higher scores on difficulty describing negative feelings used greater variety of emojis when describing negative feelings, while higher scores on externally oriented thinking used less variety of emojis when describing positive feelings. This may be related to greater and lesser interoceptive ability. Further research is warranted. Findings support facet-level over total scores analyses in informing more nuanced understandings of the impacts of alexithymia in interpersonal communication. They suggest that text messaging may attenuate the impacts of the verbal deficits associated with higher-level alexithymia and that emoji use may be more sensitive to specific alexithymic difficulties in particular valence contexts.

Alexithymia modulates the attitudes towards odors but not the olfactory abilities or the affective reactions to odors.

Although emotion and olfaction are closely linked, only a few studies have investigated olfactory processing in alexithymia, a condition characterized by altered emotional processing. These results do not allow comprehensive conclusions on whether individuals with alexithymia present lower olfactory abilities or only altered affective reactions and awareness of odors. Three pre-registered experiments were conducted to clarify this relation. We assessed olfactory functions, the affective qualities of odors, the awareness of odors, the attitudes towards them, and the ability to form olfactory images in the mind. Bayesian statistics were used to assess differences between low, medium and high alexithymia groups, and Linear Mixed Models (LMMs) were applied to investigate the modulation of the affective and cognitive components of alexithymia. We observed that individuals with a high level of alexithymia presented the same olfactory abilities, and did not show differences in their rating of odors compared to individuals with low alexithymia levels, while they reported lower levels of social and common odor awareness and a more indifferent attitude towards odors. Olfactory imagery was not affected by alexithymia level, and the affective and cognitive components of alexithymia, when considered separately, modulated olfactory perception differently. Learning more about olfactory perception in individuals with alexithymia leads to a better understanding of how alexithymia impacts the perception of hedonic stimuli coming from different sensory modalities. Our results imply that treatment goals for alexithymia should be the enhancement of the conscious perception of odors, supporting the use of mindfulness-based protocols in the alexithymia treatment.

Effects of Alexithymia on Moral Decision-Making in Sacrificial Dilemmas: High Alexithymia is Associated with Weaker Sensitivity to Moral Norms.

Although several studies have investigated the association between alexithymia and moral decision-making in sacrificial dilemmas, the evidence remains mixed. The current work investigated this association and how alexithymia affects moral choice in such dilemmas. The current research used a multinomial model (ie, CNI model) to disentangle (a) sensitivity to consequences, (b) sensitivity to moral norms, and (c) general preference for inaction versus action irrespective of consequences and norms in responses to moral dilemmas. Higher levels of alexithymia were associated with a greater preference for utilitarian judgments in sacrificial dilemmas (Study 1). Furthermore, individuals with high alexithymia showed significantly weaker sensitivity to moral norms than did those with low alexithymia, whereas there were no significant differences in sensitivity to consequences or a general preference for inaction versus action (Study 2). The findings suggest that alexithymia affects moral choice in sacrificial dilemmas by blunting emotional reactions to causing harm, rather than through increased deliberative cost-benefit reasoning or general preference for inaction.

Alexithymia and emotion regulation

BackgroundAlexithymia is a key transdiagnostic risk factor for emotion-based psychopathologies. Conceptual models specify that this is because alexithymia impairs emotion regulation. However, the extent of these putative emotion regulation impairments remains underexplored. Our aim in this study was to begin to address this gap by examining whether people with high, average, or low levels of alexithymia differ in the types of emotion regulation strategies they typically use. MethodGeneral community adults from the United States (N = 501) completed a battery of alexithymia and emotion regulation measures. Participants were grouped into high, average, and low alexithymia quantiles. ResultsAfter controlling for demographics and current levels of distress, the high, average, and low alexithymia groups differed in their use of cognitive and behavioral emotion regulation strategies. Compared to the other groups, the high alexithymia group reported lesser use of generally adaptive regulation strategies (cognitive reappraisal, approaching problems, and seeking social support) and greater use of generally maladaptive regulation strategies (expressive suppression, behavioral withdrawal, ignoring). LimitationsOur data were cross-sectional and from self-report questionnaires. Future work in other cultural groups would be beneficial. ConclusionsOur results support the view that alexithymia is associated with impaired emotion regulation. In particular, people with high alexithymia seem to exhibit a less adaptive profile of emotion regulation strategies. Direct targeting of these emotion regulation patterns in psychotherapy may therefore be a useful pathway for the treatment of emotional disorder symptoms in people with high alexithymia.

Attentional Processing of Unpleasant Stimuli in Alexithymia.

Alexithymia is a multi-faceted personality trait defined by difficulties in identifying and describing emotions and is considered a risk factor for multiple psychiatric disorders. Current alexithymia research debates the type of attention bias involved in the processing of negative emotional information, especially in anxiety-evoking situations that are frequently associated with stress states. Relatedly, this study aims to examine the role of emotional influence on the attentional processing of Taiwanese alexithymic individuals. Using the Chinese version of the Toronto Alexithymia Scale-20 (TAS-20), individuals with high alexithymia (HA: TAS > 60, n = 26; Mage = 23.36) and individuals with low alexithymia (LA: TAS < 39, n = 26; Mage = 25.76) were recruited. Participants performed an emotional counting Stroop task preceded by anxiety-evoking (threatening and aversive pictures) or neutral pictures. Reaction times (RTs) of the emotional Stroop task were compared between HA and LA groups. Our results demonstrate that compared to individuals with LA, individuals with HA show early avoidance tendency (i.e., allocate less attentional resources to anxiety-evoking stimuli), and that negative affect therefore does not interfere with subsequent attention processing during the Stroop task, resulting in faster RT for unpleasant stimuli (Mthreatening = 683.87, Maversive = 685.87) than neutral stimuli (Mneutral = 695.64) (ps < .05). In addition, the attentional bias toward specific types of negative emotion was not differentiated in individuals with HA (p < .05), suggesting that alexithymic individuals' emotion schemas may be underdeveloped in terms of ability to specify exact emotions. This study provides evidence regarding early sensitization to negative stimuli during information processing, consistent with the notion that alexithymia is related to avoidant emotion regulation processes.

Dispositional mindfulness, alexithymia and sensory processing: Emerging insights from habituation of the acoustic startle reflex response

There is growing evidence of beneficial effects of mindfulness developed through engaging in mindfulness training/practices on sensory and cognitive processing, emotion regulation and mental health. Mindfulness has also been conceptualised as a dispositional ‘trait’, i.e. the naturally-occurring ability of meditation-naïve individuals to display, in varying degree, a non-judgmental non-reactive present-moment awareness in everyday life. In this study we examined possible associations between dispositional mindfulness, alexithymia and sensory processing. Eye-blink startle responses to acoustic stimuli of varying intensity [90-dB or 100-dB over 70-dB (A) background] were assessed in 26 meditation-naïve adults (50 % men) using electromyographic recordings of the orbicularis muscle. All participants completed the Five Facet Mindfulness Questionnaire and the 20-item Toronto Alexithymia Scale. A negative association was found between dispositional mindfulness and alexithymia (r = −0.513). There was stronger startle habituation to 100-dB, compared to 90-dB probes. Stronger startle habituation (larger negative habitation slope values) to 100-dB probes was significantly associated with higher dispositional mindfulness (r = −0.528) and with lower alexithymia at trend level (r = 0.333). As indicated by commonality analysis, 10.6 % of explained variance in habituation (100-dB probes) was common to both alexithymia and mindfulness, 17.3 % was unique to mindfulness, but alexithymia made negligible unique contribution (0.5 %). These findings indicate similar startle habituation pattern in people with a high level of dispositional mindfulness to that reported previously by Antonova et al. (2015) in people with moderate mindfulness meditation practice intensity. Future studies should investigate the mechanisms, such as interoceptive awareness, that might underly these relationships.

The Influence of Personality Traits on Specific Coping Styles and the Development of Posttraumatic Stress Symptoms following Acute Coronary Syndrome: A Cluster Analytic Approach

Objective: A growing body of literature suggests a relationship between personality traits and posttraumatic stress disorder (PTSD) symptoms after acute coronary events (ACS). However, specific personality profiles have not been examined in patients after ACS. Thus, the aim of the present study was to examine personality profiles created from response patterns on the resilience, alexithymia and type D personality (TDP) scales and to examine associations with PTSD symptoms, symptom clusters and coping styles among a sample of ACS patients. Methods: A cluster analytic approach was utilized to identify risk profiles based on personality variables and a series of ANOVAs in 154 patients. Post hoc analyses were conducted to examine the relationship between each profile, and interviewer-rated PTSD symptoms and different coping styles. Results: The analyses indicated a three-cluster solution, including low- (high resilience, low alexithymia and non-TDP), medium- (average resilience, average alexithymia and non-TDP) and high-risk (low resilience, high alexithymia and TDP) profiles. Clusters differed significantly in all three coping subscales. At 3-month follow up, clusters differed significantly in all three PTSD subscales (re-experiencing, avoidance and hyperarousal). At 12-month follow up, the differences remained significant for the hyperarousal subscale only. Conclusions: The personality profiles identified and the respective associations to PTSD symptoms and coping strategies highlight the potential impact for the psychological adjustment following ACS.

Relationships between alexithymia, interoception, and emotional empathy in autism spectrum disorder.

Empathy, the ability to understand and share the emotions of others, is a necessary skill for social functioning and can be categorized into cognitive and emotional empathy. There is evidence to suggest that individuals with autism spectrum disorder have difficulties with cognitive empathy, the ability to imagine how another person is thinking or feeling. However, it is unclear if individuals with autism spectrum disorder struggle with emotional empathy, the ability to share and feel emotions others are experiencing. Self-report and interview data were collected to explore the relationships between interoception (individuals' self-reported awareness of sensation from their body such as thirst, heartbeat, etc.), alexithymia (an individual's ability to describe and distinguish between their own emotions), and emotional empathy in 35 youth with autism spectrum disorder and 40 typically developing youth. Greater personal distress to others' emotions and greater difficulty describing and recognizing self-emotions were associated with reporting fewer physical sensations in the body when experiencing emotion in the autism spectrum disorder group. The results of this study suggest that while autism spectrum disorder youth with concomitant alexithymia may experience emotional empathy differently, it should not be characterized as an absence of a capacity for emotional empathy.

Parental-Bonding and Alexithymia in Adolescents with Anorexia Nervosa, Their Parents, and Siblings.

Anorexia nervosa (AN) patients and their family-members share alexithymia, anxiety, depression, and other psychological symptoms, in the context of altered attachment. These domains have been individually studied in the context of eating disorders; few attempts have been made to study their interaction, especially including family members. In this study, alexithymia, parental-bonding, and psychopathology were assessed in 32 Italian families consisting of an adolescent AN patient, a sibling, and their parents. We aimed to (a) describe a sample of Italian families with a child affected by AN, notably including siblings; (b) investigate interactions between assessed constructs in patients and their siblings; and (c) investigate possible intergenerational effects. Results showed high alexithymia and psychopathological symptoms in patients but not in siblings, although the latter reported high obsession–compulsion and paranoid ideation scores. Patients’ and siblings’ alexithymia correlated with psychopathology. Parents reported generally low alexithymia. Perceived parental bonding was found to be suboptimal in most participants, yet no clear relationship was found between specific parenting styles and other measured traits, nor did we find any other relevant intergenerational effect. Anorexia nervosa implies psychological difficulties for all family members. Siblings’ psychopathological traits are especially concerning and currently understudied. Implications for future research and clinical interventions are discussed.

Adolescents' Attachment to Parents and Reactive-Proactive Aggression: The Mediating Role of Alexithymia.

Aggressive behaviors can serve different functions, which might be understood by distinguishing between reactive (RA) and proactive (PA) aggression. Few studies were conducted on adolescents’ family precursors and emotional processes associated with RA or PA. Accordingly, the current study compared RA and PA by evaluating their association with adolescents’ attachment to parents and alexithymia. N = 453 Italian adolescents aged 15–19 years (Mage = 16.48; SD = 0.69; 33.6% males) participated in the study filling in self-report measures. Results showed that PA and RA are significantly associated and that PA was higher among males. Moreover, four mediational models were performed to assess the influence of adolescents’ attachment to mothers vs. fathers on RA or PA, considering the mediating role of alexithymia. Gender was included as a covariate. Mediational models’ results showed a direct and indirect effect, through lower alexithymia, of adolescents’ attachment to mothers and fathers on RA. Differently, only attachment to mothers showed a direct effect on PA, while attachment to fathers only an indirect effect, mediated by lower alexithymia, on PA was shown. Findings support the greater relevance of emotional processes for RA while highlighting the differential contribution of adolescents’ attachment to mothers vs. fathers upon PA. Implications are discussed, and suggestions for future research are provided.

Dissociation in patients with non-affective psychosis: Prevalence, symptom associations, and maintenance factors

Dissociation is problematic in its own right for patients with psychosis but may also contribute to the occurrence of psychotic experiences. We therefore set out to estimate in a large cohort of patients with psychosis the prevalence of dissociative experiences, and assess using network models the relationships between dissociation, its potential maintenance mechanisms, and mental health symptoms.902 patients with non-affective psychosis attending UK mental health services participated. Both an undirected model and a partially directed network model were estimated to identify potential relationships between ‘felt sense of anomaly’ dissociative experiences, paranoia, hallucinations, psychological wellbeing, sleep, and six potential maintenance mechanisms (affect intolerance, perseverative thinking, general self-efficacy, alexithymia, cognitive appraisals, and cognitive-behavioural responses to dissociation).617 patients (65.4%) had experienced at least one dissociative symptom regularly over the past fortnight, with the average number experienced being 8.9 (SD = 8.0). Dissociation had direct relationships with paranoia, hallucinations, low psychological wellbeing, cognitive appraisals, cognitive-behavioural responses to dissociation, perseverative thinking, and low alexithymia. Dissociation was a probable cause of hallucinations (94.21% of 50,000 sampled directed acyclic graphs), with a trend towards also being a cause of paranoia (86.25% of 50,000 sampled directed acyclic graphs).Approximately two-thirds of patients with psychosis experience regular dissociative experiences. Dissociation is associated with low psychological wellbeing, and it is likely to have a direct causal influence on psychotic symptoms. Catastrophic cognitive appraisals, cognitive-behavioural responses to dissociation, factors related to affect sensitivity, and perseverative thinking may contribute to the occurrence of dissociation.

Trait Emotional Intelligence and School Burnout Discriminate Between High and Low Alexithymic Profiles: A Study With Female Adolescents.

Alexithymic traits, which entail finding it difficult to recognize and describe one’s own emotions, are linked with poor trait emotional intelligence (TEI) and difficulties in identifying and managing stressors. There is evidence that alexithymia may have detrimental consequences for wellbeing and health, beginning in adolescence. In this cross-sectional study, we investigated the prevalence and incidence of alexithymia in teenage girls, testing the statistical power of TEI and student burnout to discriminate between high- and low-alexithymic subjects. A sample of 884 female high school students (mean age 16.2 years, age range 14–19) attending three Italian academic-track high schools (social sciences and humanities curriculum) completed self-report measures of alexithymia, school burnout, and TEI. Main descriptive statistics and correlational analysis preceded the discriminant analysis. The mean alexithymia scores suggest a high prevalence of alexithymia in female adolescents; as expected, this trait was negatively correlated with TEI and positively associated with school burnout. Participants with high vs. low alexithymia profiles were discriminated by a combination of TEI and burnout scores. High scores for the emotionality and self-control dimensions of TEI were strongly associated with membership of the low alexithymia group; high scores for the emotional exhaustion dimension of school burnout were indicative of membership of the high alexithymia group. These findings suggest crucial focuses for educational intervention: efforts to reduce the risk of emotional exhaustion and school burnout should especially concentrate on enhancing emotional awareness and self-control skills, both strongly associated with low levels of alexithymia.

Life satisfaction of veterans with post-traumatic stress disorder: The predictive role of cognitive flexibility and alexithymia

Veterans with post-traumatic stress disorder have low life satisfaction and this exacerbates their symptoms. Life satisfaction is the result of each person's cognitive assessment of life based on their own unique criteria and circumstances. Therefore, the present study was conducted to predict the life satisfaction of veterans with post-traumatic stress disorder based on cognitive flexibility and alexithymia. In this descriptive-correlational study, 120 veterans with post-traumatic stress disorder who were hospitalized and treated in Isar Psychiatric Hospital in Ardabil in 2019 were selected as the available sample and examined. Data collection tools were Diner et al.’s Life Satisfaction Questionnaire, Dennis and Vander wall Cognitive Flexibility Questionnaire, and Toronto Emotional Dysfunction Questionnaire. Data were analyzed using Pearson correlation test and multiple regression analysis using SPSS 23 statistical software. Life satisfaction of veterans with post-traumatic stress disorder had a positive and significant relationship with cognitive flexibility and a negative and significant relationship with Alexithymia (P<0.05). Also, cognitive flexibility and alexithymia of 68% of the variance scores predicted the level of life satisfaction of veterans with post-traumatic stress disorder (P<0.001). High cognitive flexibility and low alexithymia improve life satisfaction in veterans with post-traumatic stress disorder. Therefore, training veterans to empower them in these areas is recommended.

Deficient auditory emotion processing but intact emotional multisensory integration in alexithymia.

Alexithymia has been associated with emotion recognition deficits in both auditory and visual domains. Although emotions are inherently multimodal in daily life, little is known regarding abnormalities of emotional multisensory integration (eMSI) in relation to alexithymia. Here, we employed an emotional Stroop‐like audiovisual task while recording event‐related potentials (ERPs) in individuals with high alexithymia levels (HA) and low alexithymia levels (LA). During the task, participants had to indicate whether a voice was spoken in a sad or angry prosody while ignoring the simultaneously presented static face which could be either emotionally congruent or incongruent to the human voice. We found that HA performed worse and showed higher P2 amplitudes than LA independent of emotion congruency. Furthermore, difficulties in identifying and describing feelings were positively correlated with the P2 component, and P2 correlated negatively with behavioral performance. Bayesian statistics showed no group differences in eMSI and classical integration‐related ERP components (N1 and N2). Although individuals with alexithymia indeed showed deficits in auditory emotion recognition as indexed by decreased performance and higher P2 amplitudes, the present findings suggest an intact capacity to integrate emotional information from multiple channels in alexithymia. Our work provides valuable insights into the relationship between alexithymia and neuropsychological mechanisms of emotional multisensory integration.

The Effect of Alexithymia on Attentional Bias Toward Emotional Stimuli in Depression: An Eye-Tracking Study.

Alexithymia—reflecting deficits in cognitive emotion processing—is highly prevalent in individuals with depressive disorders. Subsequently, mixed evidence for attentional bias is found in these individuals. Alexithymia may be a potential influencing factor for attentional bias in depression. In the current study, 83 currently depressed (CD) and 76 never-depressed (ND) controls completed an eye-tracker task consisting of valenced (non)-social pictures. Alexithymia scores were also included as a moderator as both a continuous and categorical measure (so high vs. low alexithymia). No group difference or moderating effect of alexithymia was found on attentional bias. Thus, alexithymic symptoms, included both dimensionally and categorically, may not influence biased attentional processing in depression compared to ND individuals. Thus, it is important to explore other potential explaining factors for the equivocal results found on biased attentional processing of emotional information in depression.

A systematic review of evidence about the role of alexithymia in chronic back pain

Individuals with alexithymia struggle to make sense of their emotions. Alexithymia has been associated with a range of physical illnesses, but may influence different illnesses differently, so to understand the role of alexithymia in illness it is important to focus on specific conditions. This article reviews evidence from ten reports published between 2000 and 2018 of studies with samples of adults with chronic back pain that used the Toronto Alexithymia Scale (TAS). The studies were conducted in Germany, Israel, Italy, Russia, Turkey and the US. Eight studies involved clinical samples and two involved public transit workers. Studies that compared participants with high and low alexithymia consistently found associations with measures of pain. The findings show that more severe alexithymia plays a role in the experience of chronic back pain, and support the incorporation of alexithymia-related elements in interventions to help people with chronic back pain improve their emotional regulation and reduce their pain-related distress.