infection, fibromyalgia, panic disorder, erectile dysfunction, sperm counts, chronic itching, glucose level regula-
tion, number of words spoken at age one, preference for negatively valenced movies, transsexualism, autism/
Asperger’s disorder, vaginismus, circumcision, dysphoric mood, schizoid personality disorder, self-injury, lack of
enhanced gamma band power, circulating cytokine profile, dissociative proneness, and neuroticism. However,
the effect sizes are generally small or moderate. This large and loose nomological network is often seen as part of
the alexithymia success story. However, when a network becomes too large and loose it suggests that there is
something wrong with the concept, or/and its measurement.
Presently, there is agreement that the following traits are core elements of the alexithymia construct /C0marked
reductions in the capacities to: fantasize, identify, verbalize, and analyze emotions (externally oriented thinking).
One would, thus, expect at least four subscales. However, there are alexithymia scales comprising 1, 2, 3, 4, 5, or
even 6 facets/subscales, indicating that alexithymia is, in its measurement, ill-defined.
When coining the term alexithymia, Sifneos (1973) clearly mentioned ‘marked constriction in experiencing
emotions’ in his description of alexithymia. However, flatness of affect was not included in his Beth-Israel
Hospital Psychosomatic Questionnaire (BIQ), and for good reason: the BIQ is an observation scale and emotional
feelings belong to the domain of first person data that cannot be observed nor reduced to third person data
(Chalmers, 1999 ). Rarely mentioned, Apfel and Sifneos (1979) also published an alexithymia self-rating question-
naire with open questions containing ten items referring to emotional feelings. Flatness of affect should, accord-
ingly, be measured in self-rating scales. Not only have Nemiah and Sifneos always stressed the importance of
this element of alexithymia ( Nemiah, 1977, 1996; Nemiah & Sifneos, 1970a, 1970b; Nemiah, Freyberger, & Sifneos
1976; Sifneos, 1973, 1991, 2000 ), alexithymia experts agree that ‘flatness of affect’ is one of the most characteristic
features of alexithymia ( Haviland & Reise, 1996a ).
There is the question as to what the criterion validity of alexithymia measures should be ( Lumley et al., 2007 ).
The most direct study would be one in which attending therapists would select a group of clearly alexithymic
individuals and non-alexithymic individuals, independent of alexithymia scores, and only measures making the
same classification could be regarded as having criterion validity. There is, only one study coming close to this
(Taylor et al., 1988 ). In this study cut-off scores for the TAS-26 were established by some kind of an iterative
method. Thus, cut-off scores were not set a priori, but posterior chosen to produce the optimal result.1Since the
alexithymia construct stems from the field of psychosomatics, correlations with psychosomatic complaints could
be the next best thing. However, there are reasons to assume that alexithymia does not induce disease and is not
specifically related to psychosomatic illness but related to unexplained bodily experiences often mistaken for
pathology ( Flannery, 1977 ). Furthermore, only some psychosomatic patients show clear alexithymic characteris-
tics ( Sifneos, 1973; Porcelli & Meyer, 2002 ). Finally, the alexithymia nomological network is too loose, and too
large to be used as a standard for alexithymia scales.
Other problems are due to the fact that (a) alexithymia is conceived as a cluster of various traits; and (b) alex-
ithymia scales are both diagnostic and research instruments.
Another question is whether scales should be unidimensional or multidimensional. If one considers alexithy-
mia as a phenomenon defined by a number of highly correlated traits, one accepts many cross-loadings, and
thus, high correlations between subscales ( Haviland, Warren, & Riggs 2000 ). In such cases, the interpretation of
subscale scores is problematic. However, although some alexithymia facets are, on face validity, correlated (iden-
tify emotions and verbalizing emotions) others are not or less (fantasize and identify emotions). Moreover, in
case of moderate total scores, extreme subscale scores still indicate specific deficits in emotion regulation, and
there are indications that different facets or combinations of alexithymia facets are related differently to other
constructs, and different types of problems ( Moormann et al., 2008; Chen, Xu, Jing, & Chan 2011 ).Vorst and
Bermond (2001) strived, therefore, to make their subscales as independent from one another as possible.
However, the lower the correlations between subscales the more problematic the interpretation of moderate sum
scores become. There is a strategy feasible in between these extremes. For instance, Bagby, Parker, and Taylor
(1994a) in their TAS-20 construction, demanded that all items should have corrected item-total correlation of
$.20 (total here defined as the remaining items on the other content domains/facets) while dismissing all items
with cross-loadings of ..35. Hence, these authors strived to items that on the one hand selectively measured
only one facet of alexithymia, while on the other hand all items also had to contain an element that referred to
other facets.
1Meganck, Inslegers, Vanheule & Desmet 2011 used some kind of golden standard, since here an observation scale had to be filled out on the
basis of various alexithymia measurements, suggesting more or less ‘true’ alexithymia scores.228 9. MEASURES OF ALEXITHYMIA
III. EMOTION REGULATION