Research evaluating the relationship of alexithymia to medical and psychiatric disorders

has been compromised by the poor psychometric properties of the instruments that have

been used to measure alexithymia. This study evaluated the psychometric properties of a

recently introduced measure of alexithymia-the revised Schalling-Szfneos Personality

Scale (SSPS-R). While the factor structure of the SSPS-R was found to be reasonably con-

gruent with the theoretical domains of the alexithymia construct, the scale lacked homo-

geneity and internal reliability. These results are compared with the reliability and

validity of other available measures of alexithymia. Recommendations are offered for

the improved assessment of alexithymia in future research studies.

-V

196 PSYCHOSOMATICS

Problems With Measuring Alexithymia

JAMES D.A. PARKER, M.A.

GRAEME J. TAYLOR, M.B., CH.B., F.R.C.P.(C)

R. MICHAEL BAGBY, PH.D.

Si-in� THOMAS

T he alexithymia construct, originally devel-

oped by Nemiah and Sifneos,”2 is generating

increasing interest in the role of emotional pro-

cessing in illness and health.� Derived initially

from clinical observations made about patients

with classical psychosomatic diseases who were

not psychologically minded and who had diffi-

culty describing their emotions,’ the construct

has since been extended and applied to patients

with a variety of medical and psychiatric disor-

ders, in particular somatization disorders?7 sub-

stance use disorders,4’5’8 and post-traumatic stress

disorders.5’9”#{176} The four components that jointly

form the construct of alexithymia are as follows:

Received November 18, 1989; revised January 30,

1990; accepted February 16, 1990. From the Department of

Psychology, York University, Toronto; the Departments of

Psychiatry, University of Toronto and Mount Sinai Hospital,

Toronto; and the Department of Psychology, Clarke Institute

of Psychiatry, Toronto, Ontario. Address reprint requests to

Dr. Taylor, Room 933, Mount Sinai Hospital, 600 University

Avenue, Toronto, Ontario, Canada, M5G 1X5.

Copyright © 1991 The Academy of Psychosomatic

Medicine.

difficulty in identifying and describing feelings,

difficulty in distinguishing between feelings and

the bodily sensations of emotional arousal, an

impoverished fantasy life, and a preference for

focusing on the details of external events rather

than inner experiences (externally oriented think-

ing).2”

Although there is a rapidly expanding body

of empirical research examining the relationship

of the alexithymia construct with medical and

psychiatric disorders, the quality of the investiga-

tions has been compromised by a failure to ade-

quately evaluate the instruments used to measure

the construct. These instruments include two in-

terviewer-rated questionnaires: the Beth Israel

Hospital Psychosomatic Questionnaire (BIQ)’2

and the Alexithymia Provoked Response Ques-

tionnaire (APRQ),9 along with several self-report

scales: the Schalling-Sifneos Personality Scale

(SSPS),’2 the Analog Alexithymia Scale

(AA5),’3 the Minnesota Multiphasic Personality

Inventory Alexithymia Scale (MMPI-A),’4 and

the Toronto Alexithymia Scale (TAS).’5 In addi-

tion, a set of Rorschach response characteris-

V

VOLUME 32- NUMBER 2 #{149}SPRING 1991 197

Parker et a!.

tics7”6 and a projective measure known as the

Symbolic Archetypal Test with nine elements

(SAT9)’7 have been used to assess certain dimen-

sions of the alexithymia construct. There is evi-

dence, however, that some of these instruments

lack adequate reliability and/or validity and show

little or no relationship to each other.’�2#{176} This

limits the interpretability and generalizability of

findings from the various research studies. Fur-

thermore, negative research outcomes may be

attributed to inadequacy of the theoretical con-

struct of alexithymia when, in fact, they may be

a consequence of inadequate measurement of the

construct.

As with measures of other personality con-

structs, instruments for measuring alexithymia

should not be used for clinical or research pur-

poses unless they have been developed in accor-

dance with contemporary standards of test

construction and have been subjected to repeated

and rigorous assessments of reliability and valid-

ity.2123 One of the most widely used alexithymia

measures is the SSPS. This is a 20-item self-re-

port questionnaire with a 4-point Likert scale.’2

Although the SSPS was constructed using items

that reflect the substantive domain of the al-

exithymia construct, it was not subjected to item

and factor analyses or assessed for internal con-

sistency prior to its use in clinical research. Sub-

sequent investigations demonstrated that the

SSPS has poor item-total correlations, poor inter-

nal consistency, and an unstable factor struc-

13,2O,24,� While several factor-analytic studies

yielded three- or four-factor solutions theoreti-

cally congruent with the alexithymia con-

struct,20’�28 very few of the SSPS items loaded

significantly on any one factor, and different

factor structures emerged in different studies

using separate samples. Recognizing that many

of the SSPS items were not contributing mathe-

matically to the factor structure of the scale,

Martin et al.28 attempted to improve the sensitiv-

ity of the SSPS by scoring only the nine items that

loaded significantly in their factor-analytic study.

However, the validity of this shortened version

of the scale has not been examined, and it is

doubtful that such a limited number of items

would ever achieve adequate levels of reliabil-

ity.23 Based on the results of these various studies,Taylor and Bagby’9 and Bagby et al.24 concluded

that the SSPS needs substantial revisions and

advised against its further use.

Sifneos29 recently made several notable

changes to the SSPS and introduced a revised

version; seven of the original items were rewrit-

ten slightly; nine items were replaced by new

items; and four items were left unchanged. In

addition, the 4-point Likert rating scale was re-

placed by a dichotomous scoring system.

The purpose of the present study was to

evaluate the psychometric adequacy of the re-

vised SSPS (SSPS-R) by examining its internal

reliability, homogeneity, and factor structure.

The results are compared with the psychometric

properties of other alexithymia measures, and

recommendations are made for improving the

measurement of the alexithymia construct.

METHODS

The subjects were 380 undergraduate students

enrolled in first- and second-year psychology

courses at York University in Ontario. All sub-

jects were volunteers and were informed prior to

completing the SSPS-R that the researchers were

conducting a study to evaluate a personality test.

There were 112 males and 268 females who

completed the SSPS-R. The mean age was

19.92±3.31 (SD) years, with no significant dif-

ference noted between the men and women stud-

ied. The subjects completed the SSPS-R in a large

classroom setting, with group sizes ranging from

50 to 250 students.

RESULTS

Reliability and Scale Homogeneity

The internal reliability of the SSPS-R was

calculated using the Kuder-Richardson Formula

(KR-20),3#{176} a special version of the coefficient

alpha23 used for scales with dichotomous items.

Estimates of internal reliability indicate the ex-

tent to which the items of a scale have common-

ality, or “hang together.” The KR-20 correlation

coefficient for the SSPS-R was 0.50, which is

Measuring Alexithymia

well below the 0.80 standard suggested by Nun­nally.23 This result indicates that the 20 items ofthe SSPS-R lack commonality and, as a whole,may not be reliably measuring the theoreticaldomains of the alexithymia construct.23.31

The mean inter-item correlation coefficientwas also calculated as an additional estimate ofinternal reliability of the SSPS-R. The meaninter-item correlation coefficient differs from theinternal reliability estimate in that it is not influ­enced by scale length; it therefore provides aclearer estimate of item homogeneity. The meaninter-item correlation coefficient for the SSPS-Rwas calculated to be 0.05. The optimal level ofitem homogeneity is generally recognized to bebetween 0.20 and 0.40.31 Mean inter-item corre­lations below 0.10 indicate that it is unlikely thata single test score (in this case a single SSPS-Rscore) could adequately represent the overallcomplexity of the items.

FinalIy, each of the 20 SSPS-R items wascorrelated with the total SSPS-R test score (cor­rected by excluding the item to be correlated fromthe total test score). TypicalIy, a "good" item hasa corrected item-total correlation in the range of0.20 to 0.30. If alI of the items have that level ofassociation with the total test score, then the itemsare collectively measuring the same construct,which will be reflected in higher internal reliabil­ity coefficients. Thirteen of the 20 SSPS-R itemshad item-total correlations less than 0.20, whichprovides some explanation for why the KR-20coefficient is so low.

Factorial Composition

In an attempt to assess the construct validityof the SSPS-R, the scale was subjected to factoranalysis. The primary purpose of this analysiswas to examine the statistical coherency and the­oretical congruity of the SSPS-R factor structure(i.e., to determine whether the factor structure ofthe scale reflects the domains of the a1exithymiaconstruct).

First, the 20 items of the SSPS-R were inter­correlated and the resulting correlation matrixwas subjected to principal axis factoring. Exam­ination of the results of this analysis revealed that

198

the two, three, four, and five factor solutions allmet the eigenvalue and scree test criteria32 forrotation. In order to determine the most reliablenumber of factors to retain for rotation, we usedthe split-half factor comparabilities method sug­gested by Everett.33 To this end, the overall sam­ple size was split into two subsamples of equalsize, hereafter referred to as sample A and sampleB, each consisting of 190 subjects. Sample A wascomprised of 57 males (20.11±I.92 years of age)and 133 females (l9.83±3.43 years). Sample Bwas comprised of 55 males (20.11±2.25 years)and 135 females (l9.91±4.00 years). For eachsample, two, three, four, and five factor solutionswere rotated to a varimax solution.

Results indicated that the three and five fac­tor solutions produced the most reliable factorstructures. The five factor solution was chosenbecause the resulting factor structure was thea­reticalIy more congruent and interpretable. Thus,the SSPS-R item correlation matrix for the entiresample (i.e., sample A and sample B combined)was subjected to principal axis factoring, and fivefactors were rotated to a varimax solution. Thisfactor structure is presented in Table I. Factorloadings of 0.30 were considered significant.Factor I is comprised ofthree items, two ofwhichseem to assess the capacity to describe feelings.Factor 2 contains items that suggest a preferencefor describing events in detail. Factor 3 containsitems that relate primarily to the ability to com­municate with others. The items on Factor4 seemto assess a preference for action. Factor 5 iscomprised of items that assess dreaming anddaydreaming.

DISCUSSION

The results of this study indicate that the SSPS-Ris not a psychometrically sound measure of thealexithymia construct. Although the factor struc­ture appears to be reasonably congruent with thetheoretical domains of the a1exithymia construct,nearly one-third of the items failed to load signif­icantly on anyone of the factors. Moreover, only7 of the 20 items showed adequate item-totalcorrelations, while the mean inter-item correla­tion was welI below what is typically expected of

PSYCHOSOMATICS

Parker et al.

TABLE 1. Factor loadings and item-total correlatioos for the SSPS-R

Item-TotalScale Items Factor 1 Factor 2 Factor 3 Fador4 Factor 5 Correlations

3. It is hard to use wordsto describe feelings. .72 .05 .09 -.01 .06 .27

I. It is easy to describesymptoms or complaintsrather than feelings. .48 .09 .02 .11 .03 .24

13. I have difficultycommunicating withpeople. .34 .00 .39 -.07 .13 .28

12. I don'l care to describedetails but rather I preferto examine how I feel. .14 .89 .03 .01 .01 .24

II. I like to be precise and todescribe everything indetail. -.01 .34 -.18 .03 -.01 .03

14. I prefer to be alone ratherthan to interact with people. .15 -.04 .44 -.05 -.08 .15

17. I find life boring most ofthe time. .25 .04 .39 .06 .01 .23

2. It is important to fmd outhow one feels about people. -.02 -.04 .35 -.01 .04 .12

20. I like people better thanIhings. -.01 -.04 .29 .10 .00 .11

4. Feelings are what makeslife wonhwhile. -.17 .17 .27 .07 .13 .14

7. When I am mad I don'tthink, I take action. .10 -.03 .05 .75 .00 .17

9. When in conflict I prefer toact quickly rather than tothink aboul it. .01 .09 .06 .52 -.04 .17

5. I lack imagination. .18 -.10 .06 -.10 .39 .16

6. I spend much timedaydreaming. -.17 .03 -.15 .00 .38 .00

19. I dream rarely. -.04 .03 .03 -.04 .36 .10

15. I always pay attention tomy surroundings rather thanconcentrate on how I feel. .16 .12 .29 .16 .33 .34

16. When I hear suspiciousnoises at night I don'l everconcentrate on how I feel. .12 .12 .10 -.03 .22 .16

18. I cannot visualize circum-stances which upset me. .14 -.04 -.01 .10 .22 .16

8. I like movies with actionrather than psychologicaldramas. .07 .18 .13 .09 .14 .20

10. When in trouble I don'tlike to act. -.15 .00 -.14 -.02 -.01 -.12

Eigenvalues 1.72 1.00 0.88 0.64 0.56

% Variance Explained 8.60 5.00 4.40 3.20 2.80

VOLUME 32· NUMBER 2· SPRING 1991 199

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Measuring Alexithymia

an internally reliable measure. Finally, the inter­nal consistency of the scale (as measured by theKR-20 coefficient) was unacceptably low (0.50)and in the same range as has been found for theSSPS.I3.20.24.25

In sum, the SSPS-R offers very little im­provement over the SSPS; in several respects itis a psychometrically poorer instrument. As withthe original SSPS, the problems with the revisedversion can be attributed primarily to the failureto use rigorous item-selection procedures whenconstructing the scale. Based on the results of thepresent study, up to two-thirds of the items on theSSPS-R should be deleted as poor items. Unfor­tunately, the remaining items would form a veryshort scale that is unlikely to be reliable andcapable of assessing adequately the theoreticaldomains of the alexithymia construct.

Similar psychometric problems have beendemonstrated with several other self-report mea­sures of alexithymia. For example, while theAAS (which was also derived from the SSPS) hasyielded a factor structure congruent with the al­exithymia construct. it has poor internal consis­tency, and the factor structure has yet to becross-validated with clinical samples. 13 The em­pirically constructed MMPI-A has poor internalconsistency, social desirability response bias, anda three-factor structure that does not adequatelyrepresent the theoretical domains of the alexithy­mia construct.20.25·34 In addition, there are incon­sistent reports of its relationship to projectivemeasures of the ability to express feelings ver­bally and to fantasize. For example, whileGreenberg and 0'Neill35 found that patients iden­tified as alexithymic on the MMPI-A were lessverbally productive and displayed less ability tofantasize on the Rorschach than patients identi­fied as nonalexithymic. Doody and Taylor6

found that the MMPI-A did not correlate withRorschach and Thematic Apperception Testmeasures of affect expression and the capacityfor fantasizing. And, contrary to the clinical im­pression that so-called alexithymic individualstend to somatize, the MMPI-A has been found tocorrelate inversely with measures of"functional"somatic complaints.20·25

By contrast. the self-report TAS meets the

200

standards of validation that are required of psy­chometric tests for use in clinical and researchsettings. Unlike the SSPS-R and other self-reportmeasures ofa1exithymia. the TAS was developedusing a construct-oriented, factor analytic ap­proach and standard item-selection procedures.15

In studies with both clinical and nonclinical pop­ulations, the TAS has demonstrated internal con­sistency, test-retest reliability, convergent anddivergent validity, and a stable and replicablefactor structure theoretically congruent with thea1exithymia construct.8.25.37-41 Criterion validityof the TAS has also been demonstrated; TASscores from a' sample of behavioral medicineoutpatients were significantly higher for patientsdesignated alexithymic than for those designatednonalexithymic on the basis of clinical interviewratings.42 The TAS has also been found to showno relationship to sociodemographic variablesand intelligence in a normal adult sample;43 fur­ther, it is sensitive to reports of somatic symp­toms in college student samples.25.37.38 Whilepreliminary TAS cutoff scores have been estab­lished,42 Haviland et aI.8.44 have recently sug­gested using TAS factor scores rather thanfull-scale scores to examine the a1exithymia con­struct. However, their suggestions are based on afactor-analytic study using a sample size of 125subjects,8 which is regarded as too small to yieldstable results.45 Furthermore, this sample con­sisted ofmixed substance abusers, and the resultsmay not be generalizable to other clinical sam­ples.

While the TAS is currently the most psycho­metrically sound measure ofthe alexithymia con­struct, psychometric conclusions based solely ona self-report instrument are generally consideredrisky.21 As in the investigation of other personal­ity constructs, alexithymia would be assessedideally by using a multi-method, multi-measureapproach. Indeed, the dimensions ofthe constructconcerned with the ability to communicate feel­ings and the capacity to fantasize may be assessedbetter with projective techniques or interviewer­rated questionnaires. However, the psychometricproperties of the SA1'9 and Rorschach alexithy­mia indices have not been fully evaluated, andthere are important limitations to the interviewer-

PSYCHOSOMATICS

rated BIQ and APRQ. For example, while theBIQ has been reported tocorrelate with the TAS40

and to have a factor structure congruent with thetheoretical domains of the alexithymia con­Struct,46 the internal consistencies of the derivedfactor scales were generally poor. Furthermore,there are reports indicating that the interraterreliability of the BIQ is suspect because the ratingof the various items is dependent on the experi­ence, bias, and style of the interviewer.19 Sriramet aI.47 have recently provided guidelines andprobes for rating the BIQ that have the potentialfor enhancing its reliability. The APRQ, whichwas derived from an early self-report form of theBIQ, minimizes interviewer bias and appears to

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be a reliable measure;9 however, it assesses affec­tive functioning only and overlooks the dimen­sion of the construct concerned with imaginalprocesses. Until well-validated projective tech­niques and interviewer-rated instruments are de­veloped, researchers should consider combiningthe TAS with ratings from clinical interviewsconducted according to the method outlined byNemiah et aI.,2 preferably examining the level ofagreement between two or more raters. Increasedand careful attention to the measurement of aI­exithymia should result in the generalizability ofresearch outcomes across various studies andenhance the systematic exploration of the al­exithymia construct.

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