Reliability and Validity of the Toronto Structured Interview for Alexithymia in A

7/27/2019 Reliability and Validity of the Toronto Structured Interview for Alexithymia in A

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Reliability and validity of the Toronto Structured Interview for Alexithymia in a

mixed clinical and nonclinical sample from Italy

Vincenzo Caretti a,, Piero Porcelli b, Luigi Solano c, Adriano Schimmenti d,R. Michael Bagby e, Graeme J. Taylor f

a Department of Psychology, University of Palermo, Palermo, Italyb Psychosomatic Unit, IRCCS De Bellis Hospital, Castellana Grotte, Italyc Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italyd Kore Department, Kore University of Enna, Enna, Italye University of Toronto and Centre for Addiction and Mental Health, Toronto, Canadaf University of Toronto and Mount Sinai Hospital, Toronto, Canada

a b s t r a c ta r t i c l e i n f o

Article history:

Received 5 October 2010

Received in revised form 12 December 2010

Accepted 22 February 2011

Keywords:

Alexithymia

Concurrent validity

Confirmatory factor analysis

Multimethod measurement

Toronto Alexithymia Scale

The reliability and validity of the Toronto Structured Interview for Alexithymia (TSIA) have been

demonstrated in previous studies with English-speaking community and psychiatric samples and a

German-speaking psychiatric sample. The aim of this study was to evaluate the psychometric properties of

the TSIA in a mixed clinical and nonclinical sample from Italy. The original English version of the TSIA was

translated into Italian and administered, along with the 20-item Toronto Alexithymia Scale (TAS-20), to 80

healthy subjects, 69 medical outpatients, and 62 psychiatric outpatients. Eighty-one videotaped interviews

were used for assessing the interrater reliability. Confirmatory factor analysis supported the hierarchical,

four-factor structure of the TSIA obtained in previous studies, with four lower-order factors nested within two

higher-order latent factors. The TSIA also demonstrated internal and interrater reliability, and concurrent

validity with the TAS-20. The results support the use of the TSIA to assess alexithymia especially when a

multimethod approach to measurement is possible.

2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction

Over the past two decades several instruments have been

developed to assess alexithymia, a construct characterized by

difficulties in identifying and describing feelings, an impoverished

fantasy life, and an externally oriented cognitive style (Nemiah et al.,

1976). The currently available instruments include self-report scales,

observer-rated questionnaires, structured interviews, and a projective

test (Lumley et al., 2007; Porcelli and Mihura, 2010; Taylor et al.,

2000). The most widely and frequently used instrument to assess

alexithymia is the self-report 20-item Toronto Alexithymia Scale

(TAS-20) (Bagby et al., 1994a), which has been translated into many

different languages and validated in diverse cultural groups (Taylor

et al., 2003; Zhu et al., 2007). As several researchers have noted,

however, a potential limitation of the TAS-20 is whether respondents

with high alexithymia are able to accurately appraise their capacity to

identify and describe their feelings (Lane et al., 1998; Lumley et al.,

2007). Other limitations include an overlap with self-report measures

of negative affect, and an absence of items for assessing fantasy

activity (these self-report items were found to be associated with a

socially desirable response bias) (Bagby et al., 1994a; Leising et al.,

2009; Lumley, 2000).

Recognizing that all methods of assessing psychological constructs

have some shortcomings, personality psychologists recommend the

useof a multimethod approachto measurementas a wayof controlling

for potentialmeasurementartifacts and thereby increasing the validity

of research findings; although the correlations between different

measures are often modest, an examination of both the convergences

and divergences between measures can increase understanding of the

underlying construct (Eid and Diener, 2006). In this same vein, Taylor

andBagby(2004),Taylor et al.(2000) havelong recommended using a

multimethod approach to assess alexithymia. Given that the construct

was formulated originally on the basis of observations made during

clinicalinterviews (Nemiah et al., 1976), Bagbyet al.(2006) developed

the Toronto Structured Interview for Alexithymia (TSIA) as an

interview-based method for measuring this construct.

TheTSIA is composed of 24 interviewitems (i.e., questions), six for

each of the four salient facets of the alexithymia construct: difficulty

identifying feelings (DIF); difficulty describing feelings to others

(DDF); an externally oriented style of thinking (EOT); and imaginal

processes (IMP). Some example questions are: Are you sometimes

Psychiatry Research 187 (2011) 432436

Corresponding author at: Department of Psychology, University of Palermo, Viale

delle Scienze, Edificio 15, 90128 Palermo, Italy. Tel.: +39 06 3219337, +39 333

6315195 (mobile); fax: +39 06 3242336.

E-mail address: [email protected] (V. Caretti).

0165-1781/$ see front matter 2011 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.psychres.2011.02.015

Contents lists available at ScienceDirect

Psychiatry Research

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puzzled or confused by what emotion you are feeling?; Is it usually

easy for you to find words to describe your feelings to others?; Do

you tend to talk to others more about daily activities rather than

feelings?; and When you think about some past eventsdo you relive

and imagine them in your mind? For each interview question there

are standardized prompts and/or probes designed to elicit responses

that are scored according to guidelines outlined in a manual (Bagby

et al., 2005).

Factor analysis of the original English-language version of the TSIAwith community and psychiatric outpatient samples identified a

hierarchical model with four lower-order factors nested within two

higher-order factors consistent with the theoretical underpinnings of

theconstruct (Bagby et al., 2006). TheDIF and DDFfacetscales formed

a single higher-order domainscale labeled AffectAwareness (AA) and

the EOT and IMP facet scales formed a single higher-order domain

scale labeled Operative Thinking (OT). The TSIA also demonstrated

acceptable levels of interrater, internal,and retest reliability, as well as

concurrent validity with the TAS-20.

Given the international interest in alexithymia research, it is

important to develop different translations of the TSIA and evaluate

the reliability and validity of these translations, as was done for the

TAS-20. A German-language translation of the TSIA was developed

and its psychometric properties evaluated with a mixed sample of

psychiatric inpatients and outpatients (Grabe et al., 2009). Confirma-

tory factor analysis supported the hierarchical, four-factor structure

obtained with the original English version, and acceptable levels of

internal and inter-rater reliability were also demonstrated. Support

for the concurrent validity of the German translation of the TSIA was

provided by significant correlations with the German translation of

the TAS-20.

The aim of the current study was to evaluate whether an Italian

translation of the TSIA would demonstrate similar psychometric

properties as the original TSIA and the German version of this

instrument. We chose a mixed clinical and nonclinical sample to

increase thevariabilityof TSIAscores acrossthe various analyses. Forthe

clinical subsample, we chose diagnostic groups known to score higher

on alexithymia measures than healthy individuals (Taylor, 2004),

thereby increasing the distribution of scores in our combined sample.

2. Methods

2.1. Translation procedures

As previously noted, the original English-language TSIA is composed of 24

interview items, six items for each of the four facets of the alexithymia construct

DIF, DDF, EOT, and IMP. Each interview question includes a set of prompts and/or

probes, keyed to the thematic content of the item, to elicit information assisting in the

accuracy of the scoring. All items are scored on a three-point scale ranging from 0 to 2

with some scores based on the frequency of the presence of a characteristic, and others

on the degree of the presence of the characteristic.

Using the same format as the original English language version, the TSIA was

translated into Italian by one of the investigators and then slightly revised after

consultation with two of the other Italian-speaking investigators. This Italian

translation was subsequently translated back into English by a bilingual teaching

assistant whose mother-tongue was English and who had previous experiencetranslating psychology texts. The back-translation was reviewed by the primary

developers of the English version of the TSIA who flagged any potential linguistic

problems, which were then discussed with the Italian translators until there was

consensus that cross-language equivalence was achieved.

2.2. Participants

Thestudysamplewascomposed ofa totalof 211(73men,and138women)subjects

whowere either healthyindividuals, psychiatric outpatients,or medical outpatients;all

wererecruitedbetweenNovember, 2007and July,2008 andall hadagreedto participate

inthestudy. Themean ageofthetotalsamplewas 36.2 years(S.D.=12.3) andthemean

years of education was 14.2 (S.D.=3.7). The healthy sample consisted of 80 (24 men,

and 56 women) individuals with a meanage of35.8 years(S.D.= 11.3);the mean years

of education was 15.8 (S.D.= 2.6). The psychiatric sample consisted of 62 (21 men, and

41 women) outpatients with a mean age of 31.8 years (S.D.=11.8); mean years of

education was 13.3 (S.D.=3.7). The medical sample consisted of 69 (28 men, and 41

women) outpatients with a mean age of 40.5 years (S.D.= 12.5); mean years of

education was 13.1 (S.D. =4.2). Gender was not distributed significantly differently

across the groups, [2(2)=1.85; P=0.40]. The healthy individuals (i.e., nonclinical

sample) had a higher level of education than both the psychiatric and medical patient

samples, [F(2, 208)=13.72, Pb0.01]; there was no difference in years of education

between the psychiatric and medical patient samples, [t (129)=0.30, P=0.76]. The

psychiatric patients were younger than the medical patients, [t(129)=4.10, P=0.01]

and healthy subjects, [t (140)=2.08, P=0.04]; and the medical patients were older

than the healthy subjects, [t(147)=2.40, P=0.02].

The psychiatric sample was composed of outpatients with generalized anxiety

disorders (n =24) and dysthymic disorders (n =14) recruited from the Department of

Developmental Psychiatry, Sapienza University of Rome and the Center for MentalHealth, ASL RomeE, and outpatients withanorexia nervosa (n =14) or bulimia nervosa

(n =10) recruited from the Center for Eating Disorders, Sant'Orsola Malpighi Hospital,

Bologna. The medical sample was composed of 69 outpatients with both essential

hypertension and circulatory problems recruited from the Hypertension Clinic,

Fatebenefratelli Hospital, Rome, and the UOC Cardiology Ward, San Filippo Neri

Hospital in Rome, who had no self-reported psychiatric diagnoses in the past 5 years.

The psychiatric and medical patients were recruited from among consecutive referrals

to these psychiatric and medical outpatient clinics.

The healthy (i.e., nonclinical) sample was composed of 80 individuals recruited

from the student body and administrative staff employees at the Sapienza University

of Rome and the University of Palermo, and from the administrative staff employees at

the IRCCS hospital of Castellana Grotte. All were recruited via advertising or

announcements at staff meetings. None of these subjects reported any current or

chronic medical and psychiatric illnesses in the past 5 years.

All subjects provided written informed consent prior to their participation. The

studywas approvedby theEthics Committees at thevarious centers where participants

were recruited. Subjects were excluded if aged b18 or N64 years, or if they were

affectedby an organic brainsyndrome or other neurologic disorder,mental retardation,

psychotic disorder, substance use disorder, chronic disease, or cancer.

2.3. Interviewers and procedures

Teninterviewers were initially givena trainingworkshopto become familiarwiththe

alexithymia construct; they were also required to read and be familiar with the TSIA

Manual (Bagby etal., 2005). Theseinterviewerswere further trained in the administration

and scoring of the interviews by two of the investigators through discussion of guidelines

forthescoring of theitems andthe correct useof thepromptsand probes. Allinterviewers

transcribed verbatim the responses to the questions and the probes and scored the 24

questions of the TSIA during the course of their interview. Each interviewer also

videotaped 6 to 12 of their interviews to be used for assessment of interrater reliability.

All participants were also administered the Italian translation of the TAS-20; the

interviewers were masked to the scores of the participants. The TAS-20 is a reliable and

valid self-report measure of alexithymia, and is comprised of three factor scales that

assess three facets of the alexithymia construct DIF, DDF, and EOT (Bagby et al.,

1994a, 1994b). The Italian translation of theTAS-20 has demonstratedfactorial validity,internal consistency in normal adult and clinical samples, and high testretest

reliability over 2 weeks (Bressi et al., 1996).

2.4. Confirmatory factor analysis (CFA)

Confirmatory factoranalysisof theTSIAwas conductedfor thetotalsample (N=211)

using LISREL8.80 with maximum likelihoodmethod of estimation(Jreskog and Srbom,

2001). Following the validation procedure for the original English language TSIA ( Bagby

et al., 2006), the factor solutions of the following models were evaluated:

(a) Model 4a = a four-factor, nonhierarchical model with items from each of the

item-facet sets serving as its own factor.

(b) Model 4b = a four-factor, hierarchical model with each of the four item-facet

sets nested under a single higher-order factor.

(c) Model 4c = a four-factor, hierarchical model with the DIF and DDF item-facet

sets nested under one higher-order factor labeled Affect Awareness (AA), and

the EOT and IMP item-facet sets nested under a second higher-order factorlabeled Operatory Thinking (OT).

(d) Model 3a = a three-factor, nonhierarchical model with items from the DIF and

DDF item-facet sets forming a single factor and EOT and IMP item-facet sets

forming separate single factors.

(e) Model 3b = a three-factor, hierarchical model with each of the three factors

identified in Model 3a nested under a single higher-order factor.

(f) Model 2a = a two-factor model with the DIF and DDF item sets forming a

single factor and the EOT and IMP item-facet sets forming a second, separate

factor.

(g) Model 2b = a two-factor, hierarchical model with the two factors identified in

Model 2a nested under a single, higher-order factor.

(h) Model 1a = a one-factor model with all of the items loading on a single factor.

Goodness offit was assessed using both absolute and incremental fit indices. The

absolute fit indices were the 2/d.f. ratio, with values between 4 and 2 indicating an

adequate fit, and values 2 indicating a good fit; the standardized root mean square

residual (SRMR), for which a cutoff valueof0.08 is recommended; and the root mean

433V. Caretti et al. / Psychiatry Research 187 (2011) 432436


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square error of approximation (RMSEA), for which values N0.10 indicate a poor fit,

b0.08 an acceptable fit, and 0.05 a good fit (Brown, 2006; Hu and Bentler, 1999). The

incremental fit indices were the comparative fit index (CFI), and the nonnormed fit

index (NNFI); for both of these indices, values N0.90 indicate an acceptable fit and

N0.95 a good fit (Hu and Bentler, 1999). The Chi square test of difference was used to

determine which of the models provided the best relative fit. Based on a priori

theoretical formulations and consistent with the empirical findings of Bagby et al.

(2006) and Grabe et al. (2009), we predicted that Models 4a and 4c would provide the

best fit to the data compared to the other models.

2.5. Interrater and internal reliability

Eighty-one of 90 videotaped interviews were of suitable audio quality for assessing

interrater reliability. These videotaped interviews were randomly assigned to the four

Italian investigators so thateach of themreceived between 15 and 25 interviews which

they reviewed and rescored. These raters were blind to the scores made by the original

interviewers as well as to the participants' TAS-20 scores.

The interrater reliability was evaluated at both the individual item level for each of

the 24 TSIA questions and at the total and subscale level. At each level of analysis, the

agreement between the interviewers and the raters was estimated. At the item level,

Cohen's kappa coefficient (Cohen, 1960) was used, and at the total TSIA and domain

and facet scale level, the two-way mixed intraclass correlation coefficient (ICC) was

used. For Cohen's kappa coefficient a probabilistic statistical significance can be

generated; for the ICC, a value N0.60 represents adequate interrater reliability, and a

value N0.80 represents good reliability (Landis and Koch, 1977).

Internal reliability and item-to-scale homogeneity of the TSIA and its domain and

facet scales were evaluated by calculating Cronbach's alpha coefficients and average

inter-item correlations (AICs). The recommended standard for Cronbach's alpha is 0.70or higher; the optimal range for themean inter-item ris0.20to 0.40(Briggs and Cheek,

1986; Nunnally and Bernstein, 1994).

The concurrent validity was examined by correlating the TSIA total scale scores,

and the domain and facet scales scores with the TAS-20 total and factor scale scores.

3. Results

3.1. Confirmatory factor analyses and model comparisons

Prior to performing CFA and obtaining estimates of goodness-of-

fit, we computed Mardia's coefficient of multivariate kurtosis to

determine if the assumption of multivariate normality was met

(Mardia, 1970). The sample was multivariate normally distributed at

the 0.05 level of significance (Mardia's statistic=1.726, P=0.08).

The goodness-of-fit indices for each of the models are shown inTable 1. The indices indicate that the four-factor models (4a, 4b, and

4c) provided good fits to the data, the three-factor and two-factor

models provided adequate fits, and the one-factor model provided a

poor fit. As predicted, model comparison testing revealed that Model

4b fit less well than Model 4a (2(2)=6.05, P=0.049) and Model 4c

(2(1)=5.73, P= 0.017), while no difference was found between

Models4a and 4c(2(1)=0.32, P=0.57). In Table 2 the item-to-facet

scale parameter estimates for the hierarchical, four-factor structure of

the TSIA are displayed for Model 4c. The mean scores and standard

deviations for the TSIA and its domain and facet scales are shown in

Table 3 for the total sample and also separately for the healthy

subjects, and the psychiatric and medical patient samples.

3.2. Intercorrelations of the TSIA and its scales

Pearson correlations between the TSIA and its domain and facet

scales for the total sample are shown in Table 4; all correlations are

statistically significant (P0.01).

Table 1

Confirmatory factor analysis goodness-of-fit results for alternative TSIA factor structure

models for the total sample (N=211).

Model Goodness offit statistics

2 (d.f.) 2/d.f. ratio SRMR CFI NNFI RMSEA (95% CI)

Four-factor models4a 345.75 (246) 1.41 0.066 0.97 0.97 0.040 (0.0280.051)

4b 351.80 (248) 1.42 0.069 0.96 0.96 0.045 (0.0330.055)

4c 346.07 (247) 1.40 0.066 0.97 0.97 0.040 (0.0280.051)

Three-factor models

3a 440.94 (249) 1.77 0.077 0.92 0.91 0.065 (0.0560.074)

3b 450.67 (250) 1.80 0.077 0.92 0.91 0.064 (0.0550.073)

Two-factor models

2a 497.74 (251) 1.98 0.078 0.91 0.90 0.068 (0.0600.077)

2b 497.74 (250) 1.99 0.079 0.91 0.90 0.069 (0.0600.077)

One-factor model

1a 570.14 (252) 2.26 0.080 0.84 0.83 0.091 (0.0830.099)

d.f. = degrees of freedom; SRMR = standardized root mean square residual; CFI =

comparative fit index; NNFI = nonnormed fit index; RMSEA (95% CI) = root mean

square error of approximation (95% confidence interval).

Table 2

Item factor loadings from the 4-factor, hierarchical model ( N=211).

Item Affect awareness Operative thinking

Factor 1 Factor 2 Factor 3 Factor 4

Difficulty identifying feelings (DIF)

Item 1 0.58

Item 5 0.49

Item 9 0.54

Item 13 0.60

Item 17 0.43

Item 21 0.52

Difficulty describing feelings (DDF)

Item 2 0.74

Item 6 0.65

Item 10 0.50

Item 14 0.75

Item 18 0.49

Item 22 0.35

Externally oriented thinking (EOT)

Item 3 0.48

Item 7 0.42

Item 11 0.62

Item 15 0.68

Item 19 0.47

Item 23 0.50

Imaginal processes (IMP)

Item 4 0.59

Item 8 0.62

Item 12 0.42

Item 16 0.62

Item 20 0.46

Item 24 0.72

Table 3

Mean scores and standard deviations for the TSIA and TAS-20 for the total sample and

for the healthy, medical, and psychiatric subsamples.

Total sample

(N=211)

Healthy subjects

(N=80)

Medical patients

(N=69)

Psychiatric patients

(N=62)

Mean (S.D.) Mean (S.D.) Mean (S.D.) Mean (S.D.)

TSIA 22.96 (8.97) 18.40 (7.90) 25.28 (8.97) 25.26 (8.26)

AA 11.05 (5.30) 8.93 (4.57) 11.43 (5.81) 13.37 (4.51)

OT 11.61 (5.01) 9.50 (4.26) 13.80 (4.63) 11.90 (5.24)

DIF 4.94 (2.84) 3.81 (2.58) 5.19 (2.95) 6.13 (2.49)

DDF 6.11 (3.13) 5.11 (2.68) 6.25 (3.61) 7.24 (2.71)

EOT 6.09 (2.99) 5.10 (2.70) 6.94 (2.97) 6.44 (3.04)

IMP 5.52 (2.91) 4.40 (2.41) 6.86 (2.79) 5.47 (3.06)

TAS-20 45.19 (12.84) 42.20 (11.10) 46.00 (14.36) 48.25 (12.52)

F1 15.69 ( 6.53) 14.89 ( 5.28) 15.31 (7.25) 17.22 ( 7.02)

F2 12.62 ( 4.89) 12.24 ( 4.65) 12.58 (5.46) 13.17 ( 4.53)

F3 16.93 ( 5.14) 15.06 ( 4.55) 18.63 (5.69) 17.50 ( 4.43)

AA = affect awareness; OT = operative thinking; DIF = difficulty identifying feelings;

DDF = difficulty describing feelings; EOT = externally oriented thinking; IMP =

imaginalprocesses; F1 = difficultyidentifying feelingsfactor;F2 = difficulty describing

feelings factor; F3 = externally oriented thinking factor.

434 V. Caretti et al. / Psychiatry Research 187 (2011) 432436


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3.3. Interrater and internal reliability

In the random subsample of 81 interviews, the ICC reliability

estimates were 0.94 (Pb0.01) for the TSIA, 0.91 (Pb0.01) for the AA

domain scale, 0.95 (Pb0.01) for the OT domain scale, 0.93 (Pb0.01)

for the DIF facet scale, 0.89 (Pb0.01) for the DDF facet scale, 0.93

(Pb0.01) for the EOT facet scale, and 0.95 (Pb0.01) for the IMP facet

scale. All of these ICC values indicate good to excellent interrater

reliability at the scale level. At the item level, the chance-corrected

Cohen's kappa coefficient was significant (Pb0.01) for all items,

ranging from 0.56 (item 5) to 0.96 (item 16), indicating moderate to

almost perfect scoring agreement between the interviewers and the

raters.

The AICs and Cronbach for the TSIA and its domain and facetscales in thetotal sampleare displayedin Table 5. The AICs werein the

recommended range of 0.20 to 0.40, indicating adequate item-to-scale

homogeneity for the TSIA and its domain and facet scales. Cronbachcoefficients for the TSIA and its domain and facet scales ranged from

0.70 to 0.86, thus showing adequate internal reliability.

3.4. Concurrent validity

The Pearson correlations between the TSIA and its domain and

facet scales and the TAS-20 and its three factor scales for the total

sample are displayed in Table 6. Almost all of the correlations are

significant. It is interesting to notethatthe DIF factor ofthe TAS-20 did

not correlate significantly with the OT domain scale of the TSIA and

correlated weakly and negatively with the IMP scale, which, in turn,

correlated positively and significantly only with theEOT factor scaleof

the TAS-20.

4. Discussion

In this study, we were successful in replicating the hierarchical,

four-factor model of the TSIA using an Italian translation of the

instrument and a mixed sample comprised of medical and psychiatricoutpatients and healthy subjects from various parts of Italy. As in the

development of the TSIA (Bagby et al., 2006), and in the study with

German-speaking psychiatric patients (Grabe et al., 2009), we used

confirmatory factor analysis to test several different structural

models. Model comparison testing revealed the superiority of both

the hierarchical, four-factor model (Model 4c) and the nonhierarchi-

cal, four-factor model (Model 4a) over three-, two-, and one-factor

models. These results, and similar findings from the study with

German-speaking patients, strongly support the hierarchical, four-

factor structure obtained by Bagby et al. (2006), who had considered

the configuration of the domain and facet scales provisional until this

structure could be replicated in other samples. Although statistically

there was no significant difference in fit between the hierarchical and

nonhierarchical four-factor models, as Bagby et al. (2006) indicated,

the hierarchical model is preferred as it is consistent with Nemiah

et al.'s (1976) theoretical conception that the alexithymia construct

comprises a deficit in affect awareness characterized by difficulties in

identifying and describing subjective emotional feelings, and an

operative thinking style (pense opratoire), which is characterized by

an absence or paucity of fantasies referable to drives and feelings

and a preoccupation with the details of external events (p. 433). The

lower-order facet scales of DIF and DDF comprise a single higher-

order domain of affect awareness (AA); and the lower-order facet

scales of EOT and IMP comprise a single higher-order domain ofoperative thinking (OT). But despite the theoretical rationale, further

research is needed to determine whether the hierarchical model is

more robust and clinically useful than the nonhierarchical model.

The finding of significant correlations among the domain and facet

scales and between these scales and the total TSIA is consistent with

the view that alexithymia is a coherent, but multifaceted construct. As

with other multifaceted constructs, however, one would expect to

find that individual TSIA facet scales sometimes correlate more

strongly than the total TSIA with measures of constructs that are

closely related to the particular alexithymia facet (Carver, 1989).

The TSIA and its domain and facet scales also demonstrated

adequate internal reliability and item-to-scale homogeneity in the

Italian sample. The Cronbach alpha coefficients and AICs all met the

criterion standards and are comparable to those found in earlierstudies (Bagby et al., 2006; Grabe et al., 2009).

A potential weakness of structured and semi-structured inter-

views is in establishing interrater agreement. With our Italian-

speaking sample we were able to achieve statistically significant

estimates of interrater reliability for the TSIA and its domain and facet

scales. Earlier studies with English-speaking community and psychi-

atric samples, and German-speaking psychiatric samples, also

demonstrated adequate to good interrater reliability for the TSIA

(Bagby et al., 2006; Grabe et al., 2009).

Concurrent validity of the Italian-language version of the TSIA was

demonstrated by the significant correlations with the Italian transla-

tion of the TAS-20. The magnitude of the correlations between the

TSIA and its facet and domain scales and the TAS-20 and its factor

scales was similar to those obtained with the English- and German-

Table 4

Pearson correlations among the TSIA and its domain and facets scales in the total

sample (N=211).

TSIA AA OT DIF DDF EOT IMP

TSIA

AA 0.88

OT 0.87 0.53

DIF 0.76 0.88 0.44

DDF 0.80 0.90 0.50 0.58

EOT 0.81 0.60 0.85 0.50 0.52 IMP 0.66 0.32 0.85 0.24 0.32 0.44

All correlations are significant at P0.01.



imaginal processes.

Table 5

Cronbach's alpha and mean inter-item correlations for the TSIA and its domain and

facet scales in the total sample (N=211).

Cronbach's AIC

Total TSIA 0.86 0.21

AA 0.82 0.27

OT 0.79 0.24

DIF 0.70 0.28

DDF 0.75 0.32

EOT 0.70 0.24

IMP 0.74 0.27

AIC = average inter-item correlation.

Table 6

Correlations between the TSIA and the TAS-20 in the total sample (N=211).

TAS-20 F1-DIF F2-DDF F3-EOT

TSIA 0.44 0.22 0.40 0.47

AA 0.53 0.39 0.49 0.38

OT 0.25 0.01 0.21 0.44

DIF 0.50 0.45 0.42 0.30

DDF 0.44 0.25 0.44 0.37

EOT 0.36 0.15 0.28 0.47

IMP 0.05 0 .16

0.07 0.28



imaginal processes. Pb0.01. Pb0.05.

435V. Caretti et al. / Psychiatry Research 187 (2011) 432436


5/5

language versions of the TSIA (Bagby et al., 2006; Grabe et al., 2009).

The magnitude of the correlation between the TSIA and TAS-20 total

scores is also similar in magnitude to correlations that have been

reported between the TAS-20 and other non-self-report measures of

alexithymia including the Observer Alexithymia Scale (Berthoz et al.,

2007; Dorard et al., 2008) and the modified Beth Israel Hospital

Psychosomatic Questionnaire (Arimura et al., 2002).

As Bagby et al. (2006) reported with their combined community

and psychiatric sample, in our mixed clinical and nonclinical sample,the TSIA DIF, DDF, and EOT facet scales correlated moderately with

their corresponding TAS-20 factor scales. The nonsignificant or low

magnitude correlations between the IMP facet scale and the TAS-20

and its factors was not unexpected since the TAS-20 does not contain

items for assessing fantasizing and other imaginal processes; the

significant, albeit weak, correlation of IMP with the EOT factor of the

TAS-20 is consistent with an earlier finding that this TAS-20 factor

correlates significantly and negatively with a measure of fantasy

(Bagby et al., 1994b).

Overall, the results of this study provide further support for the

reliability and validity of the TSIA most generally and for the Italian

language version more specifically. Moreover, the good to excellent

estimates of interrater reliability support Bagby et al.'s (2006) view

that non-expert research assistants can be trained to administer and

score theTSIA.Althoughfurther studies areneeded to assessthe retest

reliability and the convergent and discriminant validity of the TSIA, it

provides a comprehensive assessment of the alexithymia construct

and can be recommended for clinical and research purposes. In

general,a multimethod approachto assessing alexithymia is preferred,

but this is not always feasible in clinical situations and in some

research investigations due to the time involved in administering the

TSIA. Whereas the standardized prompts and probes of the TSIA

permit an assessment that avoids the potentiallimitation of self-report

measures that assume that respondents are aware of any deficits in

emotionalself-awareness,the TAS-20 has the advantageof being quick

to administer, inexpensive, and simple to score. The use of both

measures would be especially useful in investigations that need to

maximizethe likelihood that subjects are correctlyclassifiedashighor

low alexithymia individuals, such as brain imaging studies whichgenerally require small size samples (Moriguchi et al., 2006).

Acknowledgments

The authors are grateful to Alessandra Ciolfi, Arianna Franchi,

Marta Lepore, Fabio Monticelli, Alessia Zangrilli, Francesca Amati,

Maria Bonadies, Michela Di Trani, Silvia Ferrara, and Luisa Pepe for

their valuable contribution in performing the interviews.

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