Is the ralationship between interoceptive sensitivity and alexithymia explained by mood

UNITED KINGDOM SWANSEA UNIVERSITY Abnormal & Clinical Psychology M.Sc PROJECT Is the Relationship between Interoceptive Sensitivity and Alexithymia Explained by Mood? Student name: LUAN HUYNH NGUYEN Student number: 921938 Supervisor: DR HAYLEY YOUNG Year of submission: 2018 Word count: 7969 ACKNOWLEDGEMENT First and foremost, I would like to express my deepest gratitude to my project supervisor, Dr Hayley Young for believing in my potential, and providing continuous support, patience, enthusiasm and valuable critiques She was not only my supervisor but also my supporter and inspirer Her guidance shed light on all of my obstacles and motivated me to work harder to complete this project She always comforts my anxiety and encourages me to the best that I can Working with her greatly enriched my experience as an international postgraduate student I appreciate all of her contribution I also would like to expression my gratitude to all of my professors, lecturers and staff at Department of Psychology, Swansea University for equipping me knowledge and skills for completing this project and for pursuing my career in this field My special thankfulness is to Dr Rachael Hunter for being my special personal mentor and supporter I am so thankful for always receiving care, support and encouragement from my friends and my colleagues at Faculty of Psychology, University of Social Sciences and Humanities, Vietnam National University I would like to express my gratitude to Dr Nga Minh To Hoang for your special support and belief on me And last but not least, I am forever grateful to my family for their unparalleled love, unfailing emotional support throughout my project and continuous encouragement despite the distance between us Your sacrifice is always in my heart DECLARATION CONTENTS ACKNOWLEDGEMENT i DECLARATION .ii ABSTRACT iv INTRODUCTION METHOD Participants Procedures Measures RESULTS 10 Sample characteristics 10 Independent relations between components of interoceptive sensibility, confounds and alexithymia 11 Relative associations between components of interoceptive sensibility and alexithymia 13 Mediation analysis 15 DISCUSSION 18 CONCLUSION 29 REFERENCES 30 APPENDIX APPENDIX A - Ethical Approval APPENDIX B - Participant Information Sheet APPENDIX C - Consent form APPENDIX D - Additional tables APPENDIX E - Distribution scores ABSTRACT Alexithymia is a personality construct characterised by difficulties describing and identifying emotions Alexithymia was evident to be associated with interoception, the ability to perceive and interpret internal bodily signals There is a limited investigation on selfevaluated interoceptive sensibility aspect (IS) and its link with alexithymia and covariates Therefore, the present cross-sectional design established the relationship between alexithymia and IS, assessed by the Multidimensional Assessment of Interoceptive Awareness and the Body Mindfulness Questionnaire (N=161) The effects of potential covariates were also examined Our study reported the significant inverse correlation between various aspects of alexithymia and IS Especially, based on regression models, we proposed and scrutinised ‗experiencing body awareness‘ and ‗trusting body awareness‘ as fundamental factors of IS in relation to alexithymia Crucially, the present research is the first to claim the mediating effects of depression and anxiety on this relationship These findings provided the new pathway to understand the interaction between IS, mood and alexithymia, thus shed light on the influence of mindful attention style and trusting attitude in IS as well as the alexithymia subtypes General Scientific Summary Several attempts have been made to establish the links between alexithymia and body perception, especially interoceptive ability The findings were robust but still hindered due to the complexity of related concepts, measuring methods and covariates that need to be controlled In terms of interoception, the trend is to investigate more on sensibility aspect, especially the ability to interpret accurately and appreciate bodily signals The present research will explore the relationship between alexithymia and interoceptive sensibility by utilising the multidimensional approach and consider the mediating effects of potential covariates INTEROCEPTIVE SENSIBILITY, ALEXITHYMIA AND MOOD INTRODUC TI ON As being first described by Sifneos (1973), alexithymia is a personality construct characterised by difficulties in describing and identifying emotions (DDF and DIF, respectively) and externally oriented thinking style (EOT) (Bagby, Taylor, & Parker, 1994) People with alexithymia typically struggle with describing and identifying different emotions caused by poor emotional vocabulary, then being unable to distinguish emotional reactions from bodily signals They also focus on external events rather than internal senses due to the lack of fantasy and imagination (Bagby et al., 1994) The prevalence of alexithymia in the general population is approximately - 13% and even much higher in psychopathological groups (McGillivray, Becerra, & Harms, 2016; Salminen, Saarijärvi, Äärelä, Toikka, & Kauhanen, 1999) Regarding classification, the concept was classified into primary and secondary alexithymia The former reflects an enduring psychological trait while the latter refers to a dependently contemporary state after the psychological distress (Messina, Beadle, & Paradiso, 2014; Freyberger, 1977) However, another approach by Moormann et al (2008) proposed five types of alexithymia based on differences in cognitive or affective deficits when using Bermond - Vorst Alexithymia Questionnaire (Vorst & Bermond, 2001) This five-factor model was evident to be more appropriate to examine this notion, compared to the above-mentioned higher-order structure (Bagby et al., 2009) Despite the differences, these classification models could contribute to explain the mixed results of the links between alexithymia and related concepts, especially body perception, among various groups of participants Body perception was widely known as the significant antecedent of alexithymia Early theories have linked body perception to emotion and emotional processes Damasio (1994) proposed the ―somatic marker hypothesis‖, arguing that emotional processes could guide or bias behavioural outcomes James (1884) also stated that the effect of emotion on the body was bidirectional and the bodily change was a part of the emotional formation INTEROCEPTIVE SENSIBILITY, ALEXITHYMIA AND MOOD Subjective feelings rely on the active interpretation of physiological changes on our bodies (Seth, Suzuki, & Critchley, 2011) On the contrary, the Cannon-Bard theory (Cannon, 1932; Bard, 1928) explained this link in a reverse direction, which stated that bodily reaction was not the cause but the result of emotions Emotions were first activated by the central nervous system then led to behavioural reactions Although the causal relationship has been controversial, emotion and body perception were evident to be inseparable These theories served as the cornerstone and provided theoretical themes to explain the mind-body connection However, due to the lack of conceptual clarity, empirical studies to further examine the topic were impeded To date, current researchers have focused on the concept of interoception, the ability to perceive and interpret internal bodily signals Recent findings have confirmed that interoception was significantly correlated with individual‘s emotional experience (Seth, 2013; Critchley, Wiens, Rotshetein, Öhman, & Dolan, 2004; Craig, 2003), which might increase our understanding of emotional anomalies and disorders However, these studies did not connect interoception with deficits in identifying and interpreting physiological cues (Forrest, Smith, White, & Joiner, 2015) In order to deepen the understanding of interoception and underlying mechanisms that associate this concept with related factors, Garfinkela, Seth, Barrett, Suzuki, and Critchley (2015) have defined three distinct types of interoception Interoceptive accuracy (or interoceptive sensitivity, Murphy et al., 2017) refers to the ability to perform accurately on objective behavioural measures Interoceptive sensibility (IS) reflects the self-evaluation of subjective interoception by using self-report questionnaires or interviews Interoceptive awareness refers to the metacognitive level of awareness of interoceptive accuracy or our awareness of our objective performance Among these concepts, interoceptive accuracy has gained more attention to be explored with various objective assessment methods (Murphy, Catmur, & Bird, 2017) On the one hand, it could INTEROCEPTIVE SENSIBILITY, ALEXITHYMIA AND MOOD provide robust evidence for the links between interoception and alexithymia On the other hand, the popularity of this concept could lead to the excessive use of objective measures regarding interoceptive accuracy Therefore, it is of notice to examine other facets of interoception to reflect the concept of interoception more fully Several investigations have been made to initially explore the relationship between alexithymia and interoception For instance, by using the heartbeat tracking task, Herbert, Herbert, and Pollatos (2011) reported the negatively predictive effect of interoception on alexithymia in all three facets Depression also significantly predicted alexithymia in regression analysis Recent finding with the same method by Shah, Hall, Catmur, and Bird (2016) depicted the negative correlation between alexithymia and atypical interoception but not autistic traits These results emphasised the role of alexithymia as the marker of poor interoception (Murphy, Brewer, Catmur, & Bird, 2017) However, by using some experimental tasks, these studies only focused on the objective aspect, or interoceptive accuracy Therefore, they cannot adequately reflect all aspects of interoception Besides, cardiac-based measures of interoception were problematic and insensitive for the nonalexithymics with low ability levels They could also be distracted by exteroceptive ability by utilising touch receptors of the chest (Murphy et al., 2017) The problem might lead to mixed findings which reported no significant correlation between subjective interoceptive accuracy and alexithymia (i.e., Zamariola, Vlemincx, Corneille, & Lumineta, 2018) Consequently, the focus on subjective aspect of interoception has been applied as a solution to explore other significant factors of IS in relation to alexithymia Due to the limitations mentioned above, more studies have been conducted to conceptualise IS and its related links Brewer, Cook, and Bird (2016) found that alexithymia was positively correlated with poor IS, measured by two newly designed but non-validated batteries (the Interoceptive Confusion Questionnaire and the State - Emotion Similarity INTEROCEPTIVE SENSIBILITY, ALEXITHYMIA AND MOOD Questionnaire) The similar finding was also reported by Zamariola et al (2018), using the Multidimensional Assessment of Interoceptive Awareness (MAIA), Interoceptive Awareness Questionnaire and Body Awareness Questionnaire These results suggested that people with high alexithymia were less likely to focus on their body but oversensitive to pain and discomfort They also lacked self-confident with their bodily cues when not feeling their body as safe and trustworthy However, these findings were questionable by the random utilisation of self-report batteries related to body awareness without any particular definition of IS On the contrary, Longarzo et al (2015) found that the correlation between IS (assessed by Self-Awareness Questionnaire) and alexithymia was significant but negative They proposed a contradictory argument that the individuals with alexithymia had some cognitive impairment then focused on physiological aspects of emotions only Therefore, they may overrate their IS than their real ability presented in objective tests This contrast in correlational direction of Zamariola‘s and Longarzo‘s studies may result from the difference in dimensions of IS or the difference in types of alexithymia that were assessed With this in mind, the current study continues to focus on IS and its link with alexithymia by using the multidimensional approach to deepen the understanding of this concept and reassure its predictive effect on alexithymia Crucially, however, the ability to subjectively perceive our bodily signals cannot solely affect our emotions and behaviours Gross (2015) proposed the situation - attention appraisal - response model, which emphasised the importance of individuals‘ interpretation and appraisal of stimuli in emotional regulation Burg, Probst, Heidenreich, and Michalak (2017) stated that the way we interpret and appreciate our body sensations would define how we react to them Therefore, positive interpretation and appreciating attitude can lead to acceptance and prevention of difficult emotions Burg et al (2017) also suggested two facets of body mindfulness, namely experiencing and appreciating body awareness, which INTEROCEPTIVE SENSIBILITY, ALEXITHYMIA AND MOOD emphasised on the role of mindful awareness and appreciation in body perception On the contrary, anxiety and hypervigilance-driven thoughts may result in emotional discomfort and maladaptive strategies such as hypochondriasis, anxiety disorders and somatisation (Mehling, 2016) To measure IS in MAIA, Mehling et al (2012) also included two factors ‗body listening and ‗trusting‘ as attitudes towards bodily cues Therefore, it has been more obvious that the interpretation and appreciation aspects are vital components of IS, which the current research would further take into account Additionally, as it was evident that alexithymia had strong links with different factors, these variables and their effects should be controlled and examined Various findings have reported the significant correlations between alexithymia and gender (Herbert et al., 2011), depression (Honkalampi, Hintikka, Tanskanen, Lehtonen, & Viinama, 2000; Marchesi, Brusamonti, & Maggini, 2000; Parker et al., 1991), anxiety (Karukivi et at., 2010; Marchesi et al., 2000) and somatisation (Lipsanen, Saarijarvi, Lauerma, 2004) Alexithymia was also highly recorded in the clinical population with depression (Honkalampi et al., 2000; Marchesi et al., 2000; Parker et al., 1991), anxiety (Karukivi et al., 2010; Marchesi et al., 2000) and those related to body dissatisfaction (Hamilton, 2008; de Berardis et al., 2007) Possibly, it was hypothesised that these factors could also predict alexithymia and mediate the relationship between alexithymia and interoception Previous studies have attempted to control their effects Shah et al (2016) measured all depression, anxiety and autistic quotient as covariates of alexithymia and interoception Results indicated that alexithymia, not autism, can predict impaired interoceptive accuracy Anxiety traits and states were also found to be a significant predictor at the trend but no longer remained its effect when alexithymia was added Only taking depression into account, Herbert et al (2011) also reported that depression significantly predicted alexithymia total score, DDF and DIF as well However, there was no more mediated analysis with advanced statistics to further explore these effects, 34 INTEROCEPTIVE SENSIBILITY, ALEXITHYMIA AND MOOD Honkalampi, K., Hintikka, J., Tanskanen, A., Lehtonen, J., Viinamaki, H (2000) Depression is strongly associated with alexithymia in the general population Journal of Psychosomatic Research, 48, 99–104 James, W (1884) What is an emotion? 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We are conducting a research on the relationship between emotional understanding and body awareness The survey should take no longer than 15 minutes Who is carrying out the research? The data are being collected by the Department of Psychology, Swansea University, under the supervision of Dr Hayley Young The research has been approved by the Department of Psychology‘s Research Ethics Committee What happens if I agree to take part? You will be asked to complete a few questionnaires online These will involve state measures of emotion and mood, somatic symptoms, emotional understanding and body awareness Demographic information will also be collected Is participation voluntary and what if I wish to later withdraw? Your participation is entirely voluntary – you not have to participate if you not want to If you decide to participate, but later wish to withdraw from the study, then you are free to withdraw at any time, without giving a reason and without penalty What will happen to the information I provide? All the data obtained will be confidential to the study You will be identified via a participation number, not by name An analysis of the information will form part of our report at the end of the study and may be presented to interested parties and published in scientific journals and related media Note that information presented in any reports or publications will be anonymous What if I have other questions? If you have further questions about this research please not hesitate to contact us: Luan Huynh Nguyen Department of Psychology Swansea University 921938@swansea.ac.uk Dr Hayley Young Department of Psychology Swansea University h.a.young@swansea.ac.uk INTEROCEPTIVE SENSIBILITY, ALEXITHYMIA AND MOOD APPENDIX C - Consent form CONSENT FORM By continuing with this survey you agree to the following: I agree to take part in the above research I have read the Participant Information Sheet, which is attached to this form I understand what my role will be in this research, and all my questions have been answered to my satisfaction I understand that participation is voluntary and also that I am free to withdraw from the research at any time, for any reason and without prejudice I have been informed that the confidentiality of the information I provide will be safeguarded I am free to ask any questions at any time before and during the study I have been provided with a copy of the Participant Information Sheet I understand that it will not be possible to identify my data at a later date, and therefore if I wish to withdraw my data from the study, I will need to so before completing the survey (by closing the web browser) I am aged 18 years or above Data Protection: I agree to the University processing personal data that I have supplied I agree to the processing of such data for any purposes connected with the Research Project as outlined to me I agree with ALL of the above  I not agree with ALL of the above  INTEROCEPTIVE SENSIBILITY, ALEXITHYMIA AND MOOD APPENDIX D - Additional tables Table D1 Reliability Analysis of All Scales and Subscales Section Cronbach‘s Alpha No of Items 885 20 TAS-20 - DDF 867 TAS-20 - DIF 902 TAS-20 - EOT 556 877 14 BMQ - Experience 908 BMQ - Appreciation 909 912 32 MAIA - Noticing 680 MAIA - Not-Distracting 647 MAIA - Not-Worrying 668 MAIA - Attention Regulation 888 MAIA - Emotional Awareness 856 MAIA - Self-Regulation 807 MAIA - Body Listening 865 MAIA - Trusting 874 BDI 938 21 BAI 930 21 SLC-90 - Somatisation 829 12 TAS-20 BMQ MAIA Note TAS = Toronto Alexithymia Scale; BMQ = Body Mindfulness Questionnaire; MAIA Multidimensional Assessment of Interoceptive Awareness; BDI = Beck Depression Inventory; BAI = Beck Anxiety Inventory; SCL-90 = Symptom Checklist 90 INTEROCEPTIVE SENSIBILITY, ALEXITHYMIA AND MOOD AS DDF DIF 26** 57** 04** 65** 101 49** 149 067 86** 119 52** 23** 91** 74** 776** -.300** -.317** -.143 -.290** -.152 -.152 -.280** -.195* -.350** 424** 372** 254** -.277** -.365** -.058 -.192* -.132 006 -.262** -.048 -.318** 547** 534** 429** Table D2 Correlation Matrix BMQ BMQ1 BMQ2 MAIA MA1 MA2 MA3 MA4 MA5 DEP ANX SOM 780** 764** 192* 633** 550** - Scale - Total score; DDF = Difficulty Describing Feelings; DIF = Difficulty Identifying F Note TAS.430** = Toronto Alexithymia 448** 392** 298** 783** Body Questionnaire; Body Awareness; BMQ2 = Appreciating Body Awar 477**Mindfulness 246** 495** 771** BMQ1 568** = Experiencing 476** 276** 462** 807** 579** 502** Multidimensional Assessment of Interoceptive Awareness - Total score; MA1 = Attention Regulation; MA2 = Emotional A 616** 436** 516** 835** 554** 621** 565** ** ** ** ** 324** MA4 368**= Body 721Listening; 417 MA5 344 541 488** -ANX = Anxiety; SOM = Somatisation * = =.448** Self-Regulation; = Trusting; DEP = Depression; -.192* -.289** -.003 -.157 -.065 152 -.324** -.024 -.351** p=< 0.01 -.226** -.134 023 -.085 -.089 160 -.199* 068 -.281** 638** -.065 -.179* 083 -.082 -.170 151 -.222* 086 -.189* 544** 646** - INTEROCEPTIVE SENSIBILITY, ALEXITHYMIA AND MOOD Table D3 One-Way Analysis of Variance of Difficulty Describing Feelings by Gender Source df SS MS F p 7.578 7.578 254 615 Within groups 130 3876.808 29.822 Total 131 3884.386 Between groups Table D4 One-Way Analysis of Variance of Difficulty Identifying Feelings by Gender Source df SS MS F p 84.931 84.931 1.711 193 Within groups 130 6452.584 49.635 Total 131 6537.515 Between groups Table D5 One-Way Analysis of Variance of Difficulty Describing Feelings by Language Source df SS MS F p 3.538 3.538 119 731 Within groups 130 3880.848 29.853 Total 131 3884.386 Between groups Table D6 One-Way Analysis of Variance of Difficulty Identifying Feelings by Language Source df SS MS F p 1.525 1.525 030 862 Within groups 130 6535.990 50.277 Total 131 6537.515 Between groups INTEROCEPTIVE SENSIBILITY, ALEXITHYMIA AND MOOD Table D7 One-Way Analysis of Variance of Difficulty Describing Feelings by Current Medication Usage Source df SS MS F p 3.746 3.746 125 724 Within groups 130 3880.640 29.851 Total 131 3884.386 Between groups Table D8 One-Way Analysis of Variance of Difficulty Identifying Feelings by Current Medication Usage Source df SS MS F p 11.169 11.169 222 638 Within groups 130 6526.346 50.203 Total 131 6537.515 Between groups INTEROCEPTIVE SENSIBILITY, ALEXITHYMIA AND MOOD Table D9 Collinearity Statistics for Regression Model of DDF Tolerance VIF Experiencing body awareness 792 1.263 Self-regulation 588 1.701 Body listening 570 1.755 Trusting 647 1.547 Experiencing body awareness 712 1.405 Self-regulation 526 1.901 Body listening 469 2.132 Trusting 589 1.699 Depression 500 1.999 Anxiety 451 2.217 Somatisation 535 1.868 Step Step Table D10 Collinearity Statistics for Regression Model of DIF Tolerance VIF Experiencing body awareness 880 1.136 Self-regulation 697 1.436 Trusting 674 1.483 Experiencing body awareness 850 1.176 Self-regulation 670 1.492 Trusting 642 1.558 Depression 514 1.946 Anxiety 457 2.188 Somatisation 546 1.832 Step Step INTEROCEPTIVE SENSIBILITY, ALEXITHYMIA AND MOOD APPENDIX E - Distribution scores a) Distribution scores of TAS-20 total score d) Distribution scores of BMQ - Total score b) Distribution scores of TAS - DDF e) Distribution scores of BMQ Experiencing c) Distribution scores of TAS - DIF f) Distribution scores of BMQ Appreciating 10 INTEROCEPTIVE SENSIBILITY, ALEXITHYMIA AND MOOD g) Distribution scores of MAIA - Total j) Distribution scores of MAIA Regulation h) Distribution scores of MAIA - Attention k) Distribution scores of MAIA - Listening i) Distribution scores of MAIA - Emotion l) Distribution scores of MAIA - Trust 11 INTEROCEPTIVE SENSIBILITY, ALEXITHYMIA AND MOOD m) Distribution scores of depression o) Distribution scores of somatisation: n) Distribution scores of anxiety: ... the link between IS and alexithymia, then to examine the influence of mediating factors on this relationship Based on the previous literature it is hypothesised that IS is correlated with alexithymia. .. Anxiety and Difficulty Identifying Emotions DISCUSSION The present study aimed to examine the link between alexithymia and IS and the effect of covariates on this relationship We hypothesised that interoceptive. .. this association between IS and alexithymia could be explained by the mediating effects of moods The current study found that depression and anxiety were the mediators of the relationship between