Emotional learning Identity learning METT Affective Prosody Task Prosody Accuracy Prosody Reaction Time (ms) Semantic Accuracy Semantic Reaction Time (ms) Conflicting Beliefs and emotions 1st order cognition 2st order cognition 1st order emotion 2nd order emotion Control questions *significant at p,0.005 level (2-tailed). doi:10.1371/journal.pone.0005751.t002 Alexithymic 79.7 (18.8) 88.7 (9.5) 74.2 (16.6) 73.2 (13.9) 4040.4 (640.7) 87.5 (7.6) 4519.1 (329.2) 93.8 (9.1) 95.3 (7.7) 85.2 (9.9) 75.4 (15.4) 97.3 (4.4) vignettes (x2 = 9.46, p = 0.002). There was no difference in performance on the first (x2 = 2.72, p = 0.10) and second order cognition (x2 = 2.17, p = 1.14) nor on second order emotion (x2 = 1.12, p = 0.29). In addition, no group difference existed on the control questions (x2 = 0.25, p = 0.87) (see Table 2). The inter rater reliability was high (r = 0.77). Discussion In this study, we observed that healthy participants with relatively high levels of alexithymia used less efficient emotion regulation strategies (i.e. more suppression, less reappraisal). They also reported less expressivity and lower impulse strength. With regard to cognitive-emotional processing, the alexithymic individ- uals were impaired at rapid recognition of emotional information from faces and, on a higher level of processing, at emotional mentalizing. Surprisingly, there were no specific deficits in processing of emotional language. None of these group differences was attributable to mood differences (on which groups did not differ). Participants scored high on the cognitive factor of alexithymia and relatively normal on the emotionalizing factor. With regard to the self report questionnaires, previous studies on emotion regulation in alexithymia have thus far focused on suppressive and repressive [8,38] strategies. Suppression, as measured by the Illness Behaviour Questionnaire [39], correlates positively with two subscales of the TAS-20: difficulty expressing feelings to others and externally oriented thinking [40]. To our knowledge, our study is the first to investigate reappraisal as an additional emotion regulation strategy to suppression, as outlined in the influential model by Gross and John [20]. Alexithymic individuals had lower reappraisal scores and higher suppression scores on the emotion regulation questionnaire. This pattern has been associated with lower levels of well-being [20]. Because reappraisal occurs early in the emotion regulation process, before the emotion response tendencies have been fully generated, it can determine the entire upcoming emotional trajectory [20]. Our novel finding of the relationship between alexithymia and difficulties with reappraisal, suggests that an enhanced focus on reappraisal might be beneficial in the therapy of alexithymia. Alexithymia and Emotion Non-Alexithymic 84.9 (13.0) 92.1 (10.4) 88.8 (9.8) 77.1 (12.5) 3875.9 (728.3) 88.4 (8.4) 4491.8 (522,5) 98.6 (3.4) 98.6 (4.0) 95.1 (8.7) 78.5 (24.2) 98.1 (2.7) F 0.90 0.99 9.60 1.77 0.59 0.32 2.44 x2 2.72 2.17 9.46 1.12 0.25 P 0.35 0.33 0.004* 0.16 0.68 0.86 0.07 0.10 1.14 0.29 0.87 0.002* The Berkeley Expressivity Questionnaire can differentiate between negative and positive emotion-expressive behavior and has been shown to have substantial correspondence with peer ratings [28]. The alexithymic group reported less behavioral expressivity for both positive and negative emotions. Additionally, their general strength of emotion response tendencies was weaker. These findings are in agreement with increased employment of suppressive emotion regulation strategies by the alexithymic group. Furthermore, the alexithymic group reported lower levels of empathy. This corroborates and extends previous research investigating empathy and alexithymia: Guttman and Laporte [41] reported lower empathy, measured with the interpersonal reactivity index – IRI [42], in alexithymic participants, defined by the TAS-20. Alexithymic individuals scored lower on the subscales perspective taking, empathic concern and scored higher on personal distress. The same pattern was demonstrated in alexithymic students [17]. Our study demonstrated the same inverse relationship in healthy alexithymic individuals, but using other measures of alexithymia and empathy. The basis for this correlation may be that feeling empathy for another person requires understanding of the other’s feeling which may in turn rely on knowing one’s own feeling. This concept would imply that alexithymia undermines empathy (but a lack of empathy should not necessarily lead to alexithymia). The behavioral emotional processing tasks extended the questionnaire findings from self to others. Questionnaires showed maladaptive processing of own emotions, while behavioral tasks showed that processing and recognizing of others’ emotions was also, quite specifically, impaired. This was evident from both the METT and the conflicting beliefs and emotion task. On the higher order emotion-processing task, the conflicting beliefs and emotions task, participants in the high alexithymic group displayed poor understanding of the first order emotional state. This can be explained by the ‘blindfeel’ hypothesis: alexithymia is characterized by a deficit in interoceptive awareness despite the fact that behavioral and autonomic reactivity are present. Alexithymics either feel nothing or do not recognize the feeling [43]. Similar to the case for empathy, knowing another person’s feeling probably requires awareness of one’s own feelings. Table 2. Mean scores (%) (S.D.) on the cognitive-emotional tasks for the high and low alexithymic groups. PLoS ONE | www.plosone.org 5 June 2009 | Volume 4 | Issue 6 | e5751