Dealing with Feelings: Characterization of Trait Alexithymia on Emotion Regulation Strategies and Cognitive-Emotional Processing Marte Swart*, Rudie Kortekaas, Andre´ Aleman NeuroImaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands Abstract Background: Alexithymia, or ‘‘no words for feelings’’, is a personality trait which is associated with difficulties in emotion recognition and regulation. It is unknown whether this deficit is due primarily to regulation, perception, or mentalizing of emotions. In order to shed light on the core deficit, we tested our subjects on a wide range of emotional tasks. We expected the high alexithymics to underperform on all tasks. Method: Two groups of healthy individuals, high and low scoring on the cognitive component of the Bermond-Vorst Alexithymia Questionnaire, completed questionnaires of emotion regulation and performed several emotion processing tasks including a micro expression recognition task, recognition of emotional prosody and semantics in spoken sentences, an emotional and identity learning task and a conflicting beliefs and emotions task (emotional mentalizing). Results: The two groups differed on the Emotion Regulation Questionnaire, Berkeley Expressivity Questionnaire and Empathy Quotient. Specifically, the Emotion Regulation Quotient showed that alexithymic individuals used more suppressive and less reappraisal strategies. On the behavioral tasks, as expected, alexithymics performed worse on recognition of micro expressions and emotional mentalizing. Surprisingly, groups did not differ on tasks of emotional semantics and prosody and associative emotional-learning. Conclusion: Individuals scoring high on the cognitive component of alexithymia are more prone to suppressive emotion regulation strategies rather than reappraisal strategies. Regarding emotional information processing, alexithymia is associated with reduced performance on measures of early processing as well as higher order mentalizing. However, difficulties in the processing of emotional language were not a core deficit in our alexithymic group. Citation: Swart M, Kortekaas R, Aleman A (2009) Dealing with Feelings: Characterization of Trait Alexithymia on Emotion Regulation Strategies and Cognitive- Emotional Processing. PLoS ONE 4(6): e5751. doi:10.1371/journal.pone.0005751 Editor: Bernhard Baune, James Cook University, Australia Received March 3, 2009; Accepted May 1, 2009; Published June 3, 2009 Copyright: 2009 Swart et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The research was partly supported by a European Science Foundation EURYI grant (N.W.O. number 044035001) awarded to AA. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. * E-mail: m.swart@med.umcg.nl Introduction Alexithymia, or ‘‘no words for feelings’’, is a personality trait characterized by difficulties in emotion regulation, difficulties in identifying, describing and communicating feelings, difficulties in differentiating feelings from bodily sensations and diminished affect-related fantasy [1,2]. Alexithymia has been reported to be a risk factor for a variety of medical and psychiatric disorders like substance use disorders, somatization, anxiety and depression [3], and even schizophrenia [4]. Moreover, alexithymia reduces life satisfaction [5]. In a large sample in the general Finnish population, the prevalence rate of alexithymia was around 10% [6]. Unraveling the psychological mechanisms underlying alex- ithymia may have important clinical and societal implications. Even though several studies have investigated the underlying mechanisms of emotional processing in alexithymia, using a variety of tasks [e.g. 7–11; for an overview see 12]; the results remain equivocal. On a basic emotional-perceptual level of processing, Suslow [10] found that the ‘difficulty describing feelings’ score on the 20-item Toronto Alexithymia Scale (TAS- 20) [13] was correlated to a facilitation effect in a priming paradigm for negative words, consistent with an enhanced automatic processing of affective information. Contradictory to these results, Vermeulen et al. [11] showed that individuals with high scores on alexithymia are less prone to process emotional information at an automatic level, as was investigated in a different priming paradigm, in which negative and positive primes (resp. angry and happy faces) were included. Only the presentation of the angry face resulted in a lower priming effect for participants with high alexithymia scores [11]. Lane and colleagues [7,8], however, reported that high alexithymic individuals perform worse on recognizing all basic emotions in an emotional perception task. This task consisted of four subtasks in which pairs of sentences and words, faces and words, sentences and faces and faces and photographs of scenes had to be matched for emotion. In line with these findings one would expect to see a lower priming effect of both happy and angry faces in the priming paradigm from Vermeulen et al. [11]. PLoS ONE | www.plosone.org 1 June 2009 | Volume 4 | Issue 6 | e5751