Thinking About One's Feelings

Copyedited by: Riza Jane B. Cortez

BRIEF REPORT

Thinking About One's Feelings Association Between Alexithymia and Cognitive Styles in a Nonclinical Population AQ1AQ2

Romina Rinaldi, PhD,*† Viorica Radian,† Mandy Rossignol, PhD,† Kendra G. Kandana Arachchige,† and Laurent Lefebvre†

Abstract: Alexithymia is described as a disturbance in the cognitive and affective processing of emotions. Little is known about the cognitive styles associated with this personality trait. In this article, we examine to what extent alexithymia is linked with poorer rational cognitive style. A total of 685 participants from a nonclinical sample completed the Toronto Alexithymia Scale–20 along with selfreported and behavioral measures of cognitive styles. Results suggest that people with a high level of self-reported alexithymia show lower rational abilities. The findings of this study extend previous work on cognitive processes underlying emotional self-regulation impairments in alexithymia, suggesting that these difficulties may be linked to a poorer use of rational process. Key Words: Alexithymia, cognition, dual-process theories, emotion (J Nerv Ment Dis 2017;00: 00–00)

A

lexithymia is a multifaced construct that includes difficulties in identifying feelings, differentiating feelings from emotion-related physical arousal, verbally describing emotions to others, and a cognitive style reported as literal, purely functional, and externally oriented (Taylor et al., 1997). It can be considered as a steady personality trait that is normally distributed among the general population (Tolmunen et al., 2011). People with high alexithymic traits show impairments in the cognitive and affective processing of emotions with behavioral, physiological, and neurological effects (Loas et al., 2001) that include amplified physiological activity and greater hormonal arousal related to pain, reduced emotion expression, reduced limbic and prefrontal activations when attempting to connect to other people feelings or express their own, and so on (Kano and Fukudo, 2013). As alexithymia is often described as a deficit in representing and understanding emotions rather than in experiencing, cognitive deficits of emotional information can be described in the framework of Bucci Multiple Code Theory. According to Bucci (2001), the human organism is a multicode and multisystem emotional information processor with three major types of information processing systems: a “subsymbolic nonverbal” system and a “symbolic” system that can be both “verbal” and “nonverbal.” The subsymbolic mode accounts for the type of intuitive and implicit processing involved in sensory and bodily functions, whereas the symbolic imagery organizes emotional information processing, with or without connecting it to words. Subsymbolic processing may be characterized as continuous or analogic, in contrast to discrete representational entities of the symbolic mode. They operate “unconsciously,” without explicit intention or direction and may therefore be experienced as, in a sense, outside of oneself or, at least, outside of one's intentional control. They occur in all sense modalities, and the crucial information

*Grand Hôpital de Charleroi, Hôpital Notre-Dame, Charleroi; and †Cognitive Psychology and Neuropsychology Department, University of Mons, Mons, Belgium. Send reprint requests to Romina Rinaldi, PhD, Hôpital Notre-Dame, Grand'rue 3, 6000 Charleroi, Belgium. E‐mail: [email protected]. Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/17/0000–0000 DOI: 10.1097/NMD.0000000000000721

concerning our bodily states comes to us primarily in subsymbolic form, just as emotional communication between people occurs primarily in this mode. However, this system is not self-sufficient. Emotional states integrate representations that are expressed both in subsymbolic (somatic and kinesthetic feelings with unintentional and analogical processing) and symbolic (conscious and/or verbalized representations) levels. The symbolic representations help translate the content of subsymbolic states, which helps to modulate our own behavior and share it with others. In this configuration, people with high levels of alexithymia would show lower emotional representation abilities at the symbolic level, reducing their abilities of cognitive control and enhancing somatization (Luminet, 2008; Nook et al., 2015; Wotschack and Klann-Delius, 2013). Indeed, several studies suggest a reduced cognitive processing of emotional information in people with high levels of alexithymia, such as difficulties in recalling emotional words (Luminet et al., 2006; Vermeulen and Luminet, 2009), working memory for emotional AQ3 items (Colligan and Koven, 2015; Di Stefano and Koven, 2012), or in processing facial expressions (see Grynberg et al., 2012 for review). Other results suggest that the lack of conscious emotional processing abilities may be the sign of a broader executive dysfunction (Koven and Thomas, 2010; Messina et al., 2014; Vermeulen and Luminet, 2009). However, as suggested by Sifneos (2000), the mechanisms of alexithymia may extend beyond traditional cognitive functions and underlie poor emotional self-awareness, poor abstract thinking, and diminished capacity to symbolically express emotions. More recent results also show a mood interference effect on emotional information processing in people with high alexithymia level (Bayot et al., 2014). Beside the relationship between cognitive and emotional processing, another major question relates to cognitive styles. Dual-process theories of reasoning consider two major cognitive styles at the extremity of a continuum between rational and experiential/ intuitive thinking. Among these theories, the cognitive-experiential self-theory, developed by Epstein in 1994, describes two systems that function in parallel and may be congruent or conflictual. On the one hand, the experiential system is thought to be automatic, preconscious, and based on previous experience and associations. On the other hand, the rational system works intentionally, based on logical relationships between events, hence involving a certain cognitive load (Epstein, 2003; Evans, 2003; Pacini and Epstein, 1999). Trends toward one or the other cognitive style can be measured either with self-reported questionnaires or reasoning tasks. Previous studies have highlighted the interest of investigating cognitive styles in psychopathology. Watkins and Teasdale (2001, 2004) AQ4 suggested that rational self-focus is a maladaptive strategy that underlies rumination and is associated with the maintenance of pathological generalized autobiographical memories in depression. In this perspective, rational thinking enhances chronic ruminative attempts to make sense of one's current or past difficulties, whereas experiential self-focus would represent a more mindful and adaptive strategy (Watkins and Teasdale, 2001, 2004). Other studies have also suggested that the cognitive styles of people with delusions might be characterized by an overreliance on intuitive processes and an underutilization of rational processes (Freeman et al., 2014; Ross et al., 2015).

The Journal of Nervous and Mental Disease • Volume 00, Number 00, Month 2017

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Rinaldi et al.

In the present study, we investigate whether these parallels between dual-process theories of normal reasoning and theories of psychopathological processes can be extended to alexithymia. As people with a high level of alexithymia are thought to be impaired in their ability to access symbolic content of emotions, we hypothesized that they would show an underinvestment of rational cognitive styles that could prevent them from accessing the meaning and symbolic content of emotion.

METHODS

we chose to present the extended seven-item version, which is less popular and shows good psychometric properties.

Statistical Analysis Statistical analyses were conducted using SPSS 21 for Windows. Descriptive statistics and nonparametric correlations were computed. Because age, education, and sex are related to alexithymia (Levant et al., 2009; Mattila et al., 2006; Pasini et al., 1992), Spearman partial AQ6 rank order correlations between alexithymia and cognitive styles were conducted controlling for these three variables.

Population and Procedure Data were collected online with Lime survey. Double participation was avoided through use of a cookie that compares IP addresses. We excluded questionnaires that reported a lack of knowledge of French, previous completion of one or several parts of the test, and past histories of neurological disorders. A total of 685 questionnaires were analyzed (396 women and 289 men; mean age, 33.58 years; SD, 12.68; with high school to postgraduate degree).

Toronto Alexithymia Scale–20 Alexithymia was assessed with the French version of the Toronto Alexithymia Scale–20 (TAS-20) (Bagby et al., 2009; Loas et al., 1995), which is a self-reported scale comprising 20 items identifying the three main factors of alexithymia: difficulty identifying feelings (DIF), difficulty describing feelings (DDF) to others, and externally oriented thinking (EOT). Items are rated on a 5-point Likert-type scale from 1 (rarely) to 5 (very often). Total scores range from 20 to 100.

Rational Experiential Inventory Attitudes regarding cognitive styles were measured with the French version of the Rational Experiential Inventory (Pacini and Epstein, 1999; Stadelhofen et al., 2004). It is composed of 40 items in which statements are rated on a 5-point Likert-type scale ranging from entirely false (1) to entirely true (5). Half of the inventory is related to the experiential/intuitive cognitive style, whereas the other concerns the rational one. Among the 20 items for each cognitive style, 10 assess the propensity to use that given style. These are called the engagement score—that is, “I enjoy intellectual challenges” (rational engagement), “I like to rely on my intuitions” (experiential engagement). The other 10 items assess the ability to use the given style and are called the ability score—that is, “I have a logical mind” (rational ability), “I trust my initial feelings about people” (experiential ability).

RESULTS T1 Descriptive statistics are reported in Table 1. Partial correlations controlling for age, sex, and education are reported in Table 2. TAS-20 global score as well as DDF, DIF, and EOT T2 scores were negatively correlated with all REI rational scores. The EOT AQ7 score also correlated negatively with all REI experiential scores.

DISCUSSION In this study, we explored the link between alexithymia and the preferential use of experiential or rational cognitive styles. Results show that the TAS-20 scores negatively correlate with REI rational scores regardless of age, sex, and education. People with a high level of alexithymia would therefore be less engaged and less able to display a rational cognitive style. This finding seems congruent with the theory of symbolic conceptualization of emotional impairments. Indeed, the rational style is described by Epstein (1994) as a set of primarily verbal, conscious, slow, and effortful processes that operate on an inferential logic with analytic and intentional operations. It is a verbal system that encodes reality in abstract symbols, words, and numbers. Therefore, if people with high alexithymia have a deficit in using rational thinking, they might tend to overly refer to an intuitive cognitive style and will maintain a preconscious and subsymbolic representation of emotions. Thus, we could have expected that they would obtain significantly higher scores for the experiential measures. Instead, our data indicate that these processes are similar among the groups. The implication of rational and experiential processes in alexithymia might therefore not be considered as necessarily asymmetrical but rather involve a specific impairment in the use of rational thinking to process emotional content. Drawing a parallel on Watkins theories for major depressive disorder, people with high alexithymia may not be more efficiently mindfully self-aware than those with lower level of alexithymia, but because of their inability to

Cognitive Reflection Test The Cognitive Reflection Test in its extended seven-item version

AQ5 has been proposed as a reasoning task (Toplak et al., 2014) in a French version. The three-item version is validated in French (Frederick, 2005; Toplak et al., 2011), and the four other items have been translated for the purpose of this study. The seven items are composed of seven problems designed to generate incorrect “intuitive” answers. Each problem reliably cues a compelling intuitive answer that the participant must reflect upon to reject it as mistaken. For example: “A bat and a ball cost $1.10. The bat costs $1 more than the ball. How much does the ball costs?” (intuitive answer = 10 cents; correct answer = 5 cents). The number of correct answers elicits an actual tendency to use a rational cognitive style, whereas the number of false intuitive answers is instead linked to an experiential cognitive style. Recent studies have highlighted the side effect of the “bat and ball problem” popularity, showing that people who had previously seen one of the three problems tend to offer better answers than others, likely because they are aware of the “intuitive trick” that made them fail initially. It is therefore suggested to control for prior exposure (Haigh, 2016). In our case, beside this prior control, 2

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TABLE 1. Descriptive Statistics (N = 685)

TAS-20 DDF TAS-20 DIF TAS-20 EOT TAS-20 global REI rational ability REI rational engagement REI rational score REI experiential ability REI experiential engagement REI experiential score CRT correct answers CRT false intuitive

Mean

SD

Cronbach's α

13.68 17.13 18.77 49.57 3.56 3.55 3.56 3.32 3.24 3.28 2.98 2.57

4.01 5.37 3.89 10.40 0.56 0.56 0.51 0.46 0.55 0.45 2.16 1.89

.720 .806 .540 .822

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Alexithymia and Cognitive Styles

TABLE 2. Partial Rank-order Correlations

AQ8

Partial r (by Sex, Age, and Education) REI rational ability REI rational engagement REI rational score REI experiential ability REI experiential engagement REI experiential score CRT correct answers CRT false intuitive

TAS-20 DDF

TAS-20 DIF

TAS-20 EOT

TAS-20 Global

−0.334* −0.239* −0.320* −0.102 −0.008 −0.058 −0.021 0.034

−0.327* −0.205* −0.297* −0.072 0.055 −0.004 −0.023 0.020

−0.261* −0.429* −0.386* −0.253* −0.219* −0.264* −0.069 0.040

−0.398* −0.361* −0.424* −0.173* −0.057 −0.124 −0.046 0.039

*p < 0.0002.

properly use rational thinking, they might be wedged in an experiential processing style by default. EOTwas the only dimension that shows significant negative correlations with both REI rational and experiential scores. This might be interpreted as the association between this specific dimension and a more global cognitive deficit, in the sense of reduced cognitive interest and reduced need for cognition. Regarding cognitive functions, Evans and Stanovich (2013) have proposed that working memory and hypothetical thinking (heuristic logic) allow the differentiation between rational processes and intuitive/ experiential ones. We hypothesized that experimentally observed deficits in cognitive control in people with high levels of alexithymia (Koven and Thomas, 2010) may be responsible for the lack of rational thinking. This pattern could be supported by the model of frontal lobe dysfunction in alexithymia (Bermond et al., 2006), which is particularly associated with a lack of emotional clarity (Koven and Thomas, 2010) that implies a symbolic access to emotional content. The lack of correlation between alexithymia and CRT scores AQ9 may be interpreted regarding the limited variance of CRT score (1 to 7) compared with the TAS-20 scores (20–100). Further studies should therefore include more than one reasoning task. Overall, these results indicate a negative correlation between alexithymia and the rational cognitive style regardless of sex or age in a nonclinical sample. Several considerations should be taken into account when interpreting our results. First, participants were not assessed with regard to mood or anxiety, which have been reported to have an interference effect in emotion identification in alexithymia (Bayot et al., 2014). Second, this study was conducted with a convenience sample, and it would be interesting to see how the results would turn out within a psychopathological population. Further studies should include a deeper exploration of intuitive and rational cognitive styles in alexithymia using a broader variety of reasoning paradigms and controlling for mood and anxiety. They should, in addition, explore the effect of these styles on daily living issues and their link to cognitive functions. To conclude, this study brings novel and interesting findings on the relationship between cognitive and emotional processing in alexithymia, as it is one of the first to investigate them within the framework of cognitive styles and dualprocess theory. DISCLOSURE The authors declare no conflict of interest. REFERENCES Bagby RM, Quilty LC, Taylor GJ, Grabe HJ, Luminet O, Verissimo R, De Grootte I, Vanheule S (2009) Are there subtypes of alexithymia? Personal Individ Differ. 47:413–418.


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