Psychiatry Research 187 (2011) 432436

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Psychiatry Research
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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, Italy Psychosomatic Unit, IRCCS De Bellis Hospital, Castellana Grotte, Italy Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy d Kore Department, Kore University of Enna, Enna, Italy e University of Toronto and Centre for Addiction and Mental Health, Toronto, Canada f University of Toronto and Mount Sinai Hospital, Toronto, Canada
b c

a r t i c l e

i n f o

a b s t r a c t
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. Conrmatory 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.

Article history: Received 5 October 2010 Received in revised form 12 December 2010 Accepted 22 February 2011 Keywords: Alexithymia Concurrent validity Conrmatory factor analysis Multimethod measurement Toronto Alexithymia Scale

1. Introduction Over the past two decades several instruments have been developed to assess alexithymia, a construct characterized by difculties 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
Corresponding author at: Department of Psychology, University of Palermo, Viale delle Scienze, Edicio 15, 90128 Palermo, Italy. Tel.: +39 06 3219337, +39 333 6315195 (mobile); fax: +39 06 3242336. E-mail address: vincenzocaretti@tiscali.it (V. Caretti). 0165-1781/$ see front matter 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2011.02.015

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 use of a multimethod approach to measurement as a way of controlling for potential measurement artifacts and thereby increasing the validity of research ndings; 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 and Bagby (2004), Taylor et al. (2000) have long recommended using a multimethod approach to assess alexithymia. Given that the construct was formulated originally on the basis of observations made during clinical interviews (Nemiah et al., 1976), Bagby et al. (2006) developed the Toronto Structured Interview for Alexithymia (TSIA) as an interview-based method for measuring this construct. The TSIA is composed of 24 interview items (i.e., questions), six for each of the four salient facets of the alexithymia construct: difculty identifying feelings (DIF); difculty describing feelings to others (DDF); an externally oriented style of thinking (EOT); and imaginal processes (IMP). Some example questions are: Are you sometimes

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puzzled or confused by what emotion you are feeling?; Is it usually easy for you to nd 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 events do 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 TSIA with community and psychiatric outpatient samples identied a hierarchical model with four lower-order factors nested within two higher-order factors consistent with the theoretical underpinnings of the construct (Bagby et al., 2006). The DIF and DDF facet scales formed a single higher-order domain scale labeled Affect Awareness (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). Conrmatory 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 signicant 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 the variability of TSIA scores across the various analyses. For the 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 experience translating psychology texts. The back-translation was reviewed by the primary developers of the English version of the TSIA who agged 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 The study sample was composed of a total of 211 (73 men, and 138 women) subjects who were either healthy individuals, psychiatric outpatients, or medical outpatients; all were recruited between November, 2007 and July, 2008 and all had agreed to participate in the study. The mean age of the total sample was 36.2 years (S.D. = 12.3) and the mean years of education was 14.2 (S.D. = 3.7). The healthy sample consisted of 80 (24 men, and 56 women) individuals with a mean age of 35.8 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 signicantly 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, P b 0.01]; 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 Mental Health, ASL Rome E, and outpatients with anorexia 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 study was approved by the Ethics Committees at the various centers where participants were recruited. Subjects were excluded if aged b 18 or N 64 years, or if they were affected by an organic brain syndrome or other neurologic disorder, mental retardation, psychotic disorder, substance use disorder, chronic disease, or cancer. 2.3. Interviewers and procedures Ten interviewers were initially given a training workshop to become familiar with the alexithymia construct; they were also required to read and be familiar with the TSIA Manual (Bagby et al., 2005). These interviewers were further trained in the administration and scoring of the interviews by two of the investigators through discussion of guidelines for the scoring of the items and the correct use of the prompts and probes. All interviewers 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 the TAS-20 has demonstrated factorial validity, internal consistency in normal adult and clinical samples, and high testretest reliability over 2 weeks (Bressi et al., 1996). 2.4. Conrmatory factor analysis (CFA) Conrmatory factor analysis of the TSIA was conducted for the total sample (N = 211) using LISREL 8.80 with maximum likelihood method 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 factor labeled 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 identied 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 identied 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 of t was assessed using both absolute and incremental t indices. The absolute t indices were the 2/d.f. ratio, with values between 4 and 2 indicating an adequate t, and values 2 indicating a good t; the standardized root mean square residual (SRMR), for which a cutoff value of 0.08 is recommended; and the root mean

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V. Caretti et al. / Psychiatry Research 187 (2011) 432436 Table 2 Item factor loadings from the 4-factor, hierarchical model (N = 211). Item Affect awareness Factor 1 Difculty 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 Difculty describing feelings (DDF) Item 2 Item 6 Item 10 Item 14 Item 18 Item 22 Externally oriented thinking (EOT) Item 3 Item 7 Item 11 Item 15 Item 19 Item 23 Imaginal processes (IMP) Item 4 Item 8 Item 12 Item 16 Item 20 Item 24 Factor 2 Operative thinking Factor 3 Factor 4

square error of approximation (RMSEA), for which values N 0.10 indicate a poor t, b 0.08 an acceptable t, and 0.05 a good t (Brown, 2006; Hu and Bentler, 1999). The incremental t indices were the comparative t index (CFI), and the nonnormed t index (NNFI); for both of these indices, values N 0.90 indicate an acceptable t and N 0.95 a good t (Hu and Bentler, 1999). The Chi square test of difference was used to determine which of the models provided the best relative t. Based on a priori theoretical formulations and consistent with the empirical ndings of Bagby et al. (2006) and Grabe et al. (2009), we predicted that Models 4a and 4c would provide the best t 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 that each of them received 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 coefcient (Cohen, 1960) was used, and at the total TSIA and domain and facet scale level, the two-way mixed intraclass correlation coefcient (ICC) was used. For Cohen's kappa coefcient a probabilistic statistical signicance can be generated; for the ICC, a value N 0.60 represents adequate interrater reliability, and a value N 0.80 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 coefcients and average inter-item correlations (AICs). The recommended standard for Cronbach's alpha is 0.70 or higher; the optimal range for the mean inter-item r is 0.20 to 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.

0.74 0.65 0.50 0.75 0.49 0.35

0.48 0.42 0.62 0.68 0.47 0.50

3. Results 3.1. Conrmatory factor analyses and model comparisons Prior to performing CFA and obtaining estimates of goodness-oft, we computed Mardia's coefcient 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 signicance (Mardia's statistic = 1.726, P = 0.08). The goodness-of-t indices for each of the models are shown in Table 1. The indices indicate that the four-factor models (4a, 4b, and 4c) provided good ts to the data, the three-factor and two-factor models provided adequate ts, and the one-factor model provided a poor t. As predicted, model comparison testing revealed that Model 4b t 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
Table 1 Conrmatory factor analysis goodness-of-t results for alternative TSIA factor structure models for the total sample (N = 211). Model Goodness of t statistics 2 (d.f.) Four-factor models 4a 345.75 (246) 4b 351.80 (248) 4c 346.07 (247) Three-factor models 3a 440.94 (249) 3b 450.67 (250) Two-factor models 2a 497.74 (251) 2b 497.74 (250) One-factor model 1a 570.14 (252) 2/d.f. ratio 1.41 1.42 1.40 SRMR 0.066 0.069 0.066 CFI 0.97 0.96 0.97 NNFI 0.97 0.96 0.97 RMSEA (95% CI) 0.040 (0.0280.051) 0.045 (0.0330.055) 0.040 (0.0280.051)

0.59 0.62 0.42 0.62 0.46 0.72

Models 4a 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 signicant (P 0.01).

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) Mean (S.D.) TSIA AA OT DIF DDF EOT IMP TAS-20 F1 F2 F3 22.96 11.05 11.61 4.94 6.11 6.09 5.52 45.19 15.69 12.62 16.93 (8.97) (5.30) (5.01) (2.84) (3.13) (2.99) (2.91) (12.84) (6.53) (4.89) (5.14) Healthy subjects Medical patients Psychiatric patients (N = 80) (N = 69) (N = 62) Mean (S.D.) 18.40 8.93 9.50 3.81 5.11 5.10 4.40 42.20 14.89 12.24 15.06 (7.90) (4.57) (4.26) (2.58) (2.68) (2.70) (2.41) (11.10) (5.28) (4.65) (4.55) Mean (S.D.) 25.28 11.43 13.80 5.19 6.25 6.94 6.86 46.00 15.31 12.58 18.63 (8.97) (5.81) (4.63) (2.95) (3.61) (2.97) (2.79) (14.36) (7.25) (5.46) (5.69) Mean (S.D.) 25.26 13.37 11.90 6.13 7.24 6.44 5.47 48.25 17.22 13.17 17.50 (8.26) (4.51) (5.24) (2.49) (2.71) (3.04) (3.06) (12.52) (7.02) (4.53) (4.43)

1.77 1.80

0.077 0.077

0.92 0.92

0.91 0.91

0.065 (0.0560.074) 0.064 (0.0550.073)

1.98 1.99

0.078 0.079

0.91 0.91

0.90 0.90

0.068 (0.0600.077) 0.069 (0.0600.077)

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 t index; NNFI = nonnormed t index; RMSEA (95% CI) = root mean square error of approximation (95% condence interval).

AA = affect awareness; OT = operative thinking; DIF = difculty identifying feelings; DDF = difculty describing feelings; EOT = externally oriented thinking; IMP = imaginal processes; F1 = difculty identifying feelings factor; F2 = difculty describing feelings factor; F3 = externally oriented thinking factor.

V. Caretti et al. / Psychiatry Research 187 (2011) 432436 Table 4 Pearson correlations among the TSIA and its domain and facets scales in the total sample (N = 211). TSIA TSIA AA OT DIF DDF EOT IMP 0.88 0.87 0.76 0.80 0.81 0.66 AA 0.53 0.88 0.90 0.60 0.32 OT DIF DDF EOT IMP Table 6 Correlations between the TSIA and the TAS-20 in the total sample (N = 211). TAS-20 TSIA AA OT DIF DDF EOT IMP 0.44 0.53 0.25 0.50 0.44 0.36 0.05 F1-DIF 0.22 0.39 0.01 0.45 0.25 0.15 0 .16 F2-DDF 0.40 0.49 0.21 0.42 0.44 0.28 0.07

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F3-EOT 0.47 0.38 0.44 0.30 0.37 0.47 0.28

0.44 0.50 0.85 0.85

0.58 0.50 0.24

0.52 0.32

0.44

All correlations are signicant at P 0.01. AA = affect awareness; OT = operative thinking; DIF = difculty identifying feelings; DDF = difculty describing feelings; EOT = externally oriented thinking; IMP = imaginal processes.

AA = affect awareness; OT = operative thinking; DIF = difculty identifying feelings; DDF = difculty describing feelings; EOT = externally oriented thinking; IMP = imaginal processes. P b 0.01. P b 0.05.

3.3. Interrater and internal reliability In the random subsample of 81 interviews, the ICC reliability estimates were 0.94 (P b 0.01) for the TSIA, 0.91 (P b 0.01) for the AA domain scale, 0.95 (P b 0.01) for the OT domain scale, 0.93 (P b 0.01) for the DIF facet scale, 0.89 (P b 0.01) for the DDF facet scale, 0.93 (P b 0.01) for the EOT facet scale, and 0.95 (P b 0.01) 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 coefcient was signicant (P b 0.01) 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 facet scales in the total sample are displayed in Table 5. The AICs were in the recommended range of 0.20 to 0.40, indicating adequate item-to-scale homogeneity for the TSIA and its domain and facet scales. Cronbach coefcients 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 signicant. It is interesting to note that the DIF factor of the TAS-20 did not correlate signicantly with the OT domain scale of the TSIA and correlated weakly and negatively with the IMP scale, which, in turn, correlated positively and signicantly only with the EOT factor scale of 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 psychiatric outpatients and healthy subjects from various parts of Italy. As in the

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 Total TSIA AA OT DIF DDF EOT IMP AIC = average inter-item correlation. 0.86 0.82 0.79 0.70 0.75 0.70 0.74 AIC 0.21 0.27 0.24 0.28 0.32 0.24 0.27

development of the TSIA (Bagby et al., 2006), and in the study with German-speaking psychiatric patients (Grabe et al., 2009), we used conrmatory 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 nonhierarchical, four-factor model (Model 4a) over three-, two-, and one-factor models. These results, and similar ndings from the study with German-speaking patients, strongly support the hierarchical, fourfactor structure obtained by Bagby et al. (2006), who had considered the conguration of the domain and facet scales provisional until this structure could be replicated in other samples. Although statistically there was no signicant difference in t 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 decit in affect awareness characterized by difculties 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 higherorder domain of affect awareness (AA); and the lower-order facet scales of EOT and IMP comprise a single higher-order domain of operative 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 nding of signicant 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 nd 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 coefcients and AICs all met the criterion standards and are comparable to those found in earlier studies (Bagby et al., 2006; Grabe et al., 2009). A potential weakness of structured and semi-structured interviews is in establishing interrater agreement. With our Italianspeaking sample we were able to achieve statistically signicant estimates of interrater reliability for the TSIA and its domain and facet scales. Earlier studies with English-speaking community and psychiatric 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 signicant correlations with the Italian translation 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-

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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 modied 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 nonsignicant 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 signicant, albeit weak, correlation of IMP with the EOT factor of the TAS-20 is consistent with an earlier nding that this TAS-20 factor correlates signicantly 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 specically. 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 the TSIA. Although further studies are needed to assess the 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 approach to 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 potential limitation of self-report measures that assume that respondents are aware of any decits in emotional self-awareness, the TAS-20 has the advantage of being quick to administer, inexpensive, and simple to score. The use of both measures would be especially useful in investigations that need to maximize the likelihood that subjects are correctly classied as high or low alexithymia individuals, such as brain imaging studies which generally require small size samples (Moriguchi et al., 2006). Acknowledgments The authors are grateful to Alessandra Ciol, 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. References
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