In summary, emotional processing on a basic perceptual level seems to be altered in alexithymia but the results are inconsistent. On a cognitive-emotional level in which cognition plays a more prominent role, such as memory for emotions or learning associations between emotions and words, Luminet et al. [9] compared people with high versus low alexithymia levels on a memory task in which participants had to recall emotional and neutral words. They had to indicate if they only ‘knew’ that they had seen the word in the list, i.e. without retrieval of any details or that they ‘remembered’ the word with details, for example, the position of the word in the list. Alexithymics gave less ‘remember’ responses for emotional words but responded the same for neutral words. Groups did not differ in ‘know’ responses for emotional and neutral words. Thus, it appears that cognitive-emotional processing differs between individuals with high and low alexithymia scores. Mentalizing, a cognitive skill also known as theory of mind (TOM), refers to understanding that others have beliefs, desires and intentions different from the self [14]. Mentalizing is impaired in psychiatric disorders which are associated with alexithymia like schizophrenia [4,15] and Asperger’s syndrome [16]. Healthy people with high alexithymia scores are also impaired in mentalizing and show reduced brain activation of medial frontal areas during mentalizing [17]. The latter study examined the participants’ ability to infer what other people think but not what they feel. This latter ability, emotional mentalizing, has not been studied but we expect it to be impaired in alexithymia. Each of the studies mentioned above focused on one stage of information processing in alexithymic individuals: basic-emotion- al, cognitive-emotional and mentalizing. It seems that high and low alexithymics differ on all three stages of emotional information processing but results are ambiguous. This ambiguity could be due to the participation of subjects from different populations and the use of different inclusion criteria in the aforementioned studies. The main purpose of the present study was to investigate differences in stages of emotional processing in individuals with high versus low verbalizing scores on the Bermond-Vorst Alexithymia Questionnaire (BVAQ) [18]. Both auditory-verbal and visual modalities at different levels of emotional processing were investigated. We included measures of early perception of facial emotional expressions, and recognition of emotional prosody. In addition, we included tasks with stronger cognitive demands. Aleman [19] proposed that learning to verbalize emotions requires development of an association between particular affective states and particular words and that alex- ithymics are less able to make these associations. Therefore, we included a task in which subjects learned associations between words and emotional facial expressions. Additionally, to investi- gate whether alexithymia is a deficit of emotional awareness in general (independent of modality) or whether it is more pronounced for language-related processes, we included tasks with emotional linguistic stimuli. Moreover, because deficits in thinking about and interpreting emotions is central to alexithymia, we included an emotional mentalizing task to probe the meta- cognitive level. To the best of our knowledge, no studies have been reported yet on emotional mentalizing abilities in alexithymics. We expected an inverse relationship between alexithymia and emotional mentalizing capacity. In addition, to shed light on behavioral emotional processing, we aimed to clarify differences in emotion regulation strategies, as described by Gross & John [20]. To this end, we included questionnaires measuring reappraisal, suppression and expressiv- ity. We were primarily interested in the aspect of ‘‘no words for feelings’’ to examine if alexithymia is related to language-related processes. Therefore, we initially selected participants based on Alexithymia and Emotion extreme scores on the verbalizing subscale of an alexithymia questionnaire, which specifically assesses the difficulty in verbal- izing one’s feelings. We anticipated that subjects with high scores on the verbalizing scale would also have higher scores on the other scales of the alexithymia questionnaire. Methods Participants A total of 493 university students filled in the verbalizing scale of the Bermond Vorst Alexithymia Questionnaire (BVAQ) [18]. Nineteen individuals with score#17 and 24 with score$26 and who gave permission to be contacted for further research, were initially selected for this study. These cutoff values were chosen to generate subgroups roughly corresponding to the lowest and highest quartiles. Participants filled in the complete BVAQ when they came for the experiment. At this time, the participants from the low alexithymia group were excluded if they scored above the overall mean verbalizing score of the 493 students (score.20.97). To ensure that the high alexithymia group was robust, reliable and reproducible, we only included participants in the high group if they still scored$26. Additionally, the mean of the high group had to be more than 1.5 SD (score.29.73) above the overall mean of the verbalizing scale. After this second selection, we included eighteen participants in the low alexithymia group (eleven females, mean age 19.3 years, SD 1.0) and sixteen in the high (nine females, mean age 20.1 years, SD 1.7). Due to the more stringent inclusion criteria for the high group, more individuals had to be excluded from this group. Groups differed significantly on the second measurement of the verbalizing scale (F(1,32) = 174.89, p,0.001). The study was approved by the Ethics Committee Psychology of the University of Groningen. All participants gave their written informed consent. Participants were paid J 12 for participation. Questionnaires Bermond-Vorst Alexithymia Questionnaire. The BVAQ is a 40-item self-report scale, which is subdivided into 5 scales (8 items per scale), comprising the alexithymia features as defined by Nemiah and Sifneos [21] and Sifneos [1], namely verbalizing, analyzing, identifying, emotionalizing and fantasizing. Previous studies have shown that the BVAQ has good psychometric properties and that the 5-factor structure of the BVAQ is supported by factor-analyses [18,22–24]. Answers are scored on a 5-point scale (1 = certainly does not apply to me, up to 5 = certainly applies to me). Higher scores indicate more alexithymic. Participants were selected on the verbalizing scale of the Bermond-Vorst Alexithymia Questionnaire (BVAQ) [18]. An example of the verbalizing scale is ‘‘I find it difficult to verbally express my feelings’’. At the time of testing, they were also asked to fill in the complete BVAQ. Bermond and colleagues have made a second order distinction, in which they distinguish a cognitive component, which comprises the verbalizing, analyzing and identifying subscales, and an affective component, consisting of the emotionalizing and fantasizing subscales. This two-factor structure has been validated in six languages and seven populations [25]. The correlation between the cognitive component of the BVAQ and the Toronto Alexithymia Scale (TAS-20) [13], which also targets the cognitive component of alexithymia, is high (r = 0.80) [18]. Emotion Regulation Questionnaire. Emotion regulation was measured with the Emotion Regulation Questionnaire (ERQ) [20]. This scale measures two emotion regulation strategies: cognitive reappraisal and expressive suppression. Cognitive PLoS ONE | www.plosone.org 2 June 2009 | Volume 4 | Issue 6 | e5751