Available online at www.sciencedirect.

com

ScienceDirect
Comprehensive Psychiatry 55 (2014) 1258 1268
www.elsevier.com/locate/comppsych

Alexithymia and adult attachment representations: Associations with the

five-factor model of personality and perceived relationship adjustment
Graeme J. Taylor a,, R. Michael Bagby b , Shauna C. Kushner c , Diane Benoit d , Leslie Atkinson e
a
Department of Psychiatry, University of Toronto and Mount Sinai Hospital, Toronto, Ontario, Canada
b
Departments of Psychology and Psychiatry, University of Toronto, and Centre for Addiction and Mental Health, Toronto, Ontario, Canada
c
Department of Psychology, University of Toronto Scarborough, Ontario, Canada
d
Department of Psychiatry, University of Toronto and Hospital for Sick Children, Toronto, Ontario, Canada
e
Department of Psychology, Ryerson University, Toronto, Ontario, Canada

Abstract

Several studies have demonstrated associations between alexithymia, adult attachment styles, personality traits, and relationship
adjustment. Only two studies, however, have explored associations between alexithymia and attachment representations. As part of a larger
investigation of maternal and infant attachment, the current study explored this association in a sample of 97 pregnant women; in addition,
measures of alexithymia and domains of the five-factor model (FFM) of personality were compared in predicting attachment security,
assessed with the Adult Attachment Interview Coherence of Mind mind scale, and perceived relationship adjustment. Alexithymia negatively
predicted coherence of mind; the domains of the FFM did not add significantly to the prediction. The Openness-to-Experience domain
predicted relationship adjustment better than alexithymia. Contrary to findings from studies that assessed adult attachment styles, coherence
of mind was unrelated to relationship adjustment and the FFM. The results suggest that alexithymia does not uniquely predict relationship
adjustment beyond the domains of the FFM.
2014 Elsevier Inc. All rights reserved.

1. Introduction processing of emotions and individual differences in levels

Alexithymia is a multi-faceted personality trait characterized
by difficulties in identifying and describing subjective feelings,
a limited imaginal capacity, and an externally orientated
cognitive style [1]. These cognitive and affective features are
thought to reflect a deficit in the cognitive processing and
regulation of emotions [2,3] and were described during the
1970s by Nemiah and Sifneos [4,5], who observed them
initially among patients with classic psychosomatic diseases.
During the past three decades the construct of alexithymia has
generated a large body of empirical research, including an
interest in identifying factors that might influence the cognitive
Corresponding author at: Department of Psychiatry, Mount Sinai Hospital,
600 University Avenue, Toronto, Ontario M5G 1X5, Canada. Tel.: +1 416
9321796.
E-mail addresses: graeme.taylor@utoronto.ca (G.J. Taylor),
rmichael.bagby@utoronto.ca (R.M. Bagby), s.kushner@utoronto.ca
(S.C. Kushner), diane.benoit@sickkids.ca (D. Benoit),
atkinson@psych.ryerson.ca (L. Atkinson).
http://dx.doi.org/10.1016/j.comppsych.2014.03.015
0010-440X/ 2014 Elsevier Inc. All rights reserved.
of emotional awareness. There is now substantial empirical
support for the validity of the construct, as well as evidence that
it is a dimensional personality trait, which overlaps conceptu-
ally with some facets of the openness to experience domain
in the five-factor model (FFM) of personality, but does not
correspond to any single higher-order personality trait domain
or lower-order (facet) trait within this model [1,6]. There is
empirical evidence also that alexithymia is associated with
several common medical and psychiatric disorders including
eating disorders, substance use disorders, post-traumatic stress
disorders, panic disorder, and functional gastrointestinal
disorders [1,3]. Other empirical research has implicated
genetic and environmental/developmental factors in the
etiology of alexithymia, in particular childhood trauma and
insecure attachments [712].
The association between alexithymia and insecure
attachment reflects the role the attachment system plays in
affect development and affect regulation [13,14]. It is well
established, for example, that attachment experiences in early
childhood influence the development of emotion schemas,
 G.J. Taylor et al. / Comprehensive Psychiatry 55 (2014) 12581268
imagination, and other cognitive skills involved in the
regulation of affective experiences [15,16]. A creative
imagination and effective emotion-regulating skills and other
mentalizing abilities are more likely to emerge in the context
of secure attachment relationships [14,17]. In a longitudinal
study across four time points between ages 17 and 36 months,
insecurely attached and disorganized children showed a delay
in developing a mentalizing language to express emotions
and other inner states [18]. Insecurely attached children also
display less positive affect and lower levels of symbolic play
than securely attached children, and are less adaptable and
competent in their subsequent relationships [19,20].
Bowlby [21] proposed that infants and children develop
mental representations (internal working models) of their
primary attachment relationships. These representations be-
come progressively more elaborated and differentiated during
childhood and adolescence, but remain relatively stable over
time thereafter [22]. The attachment representations of adults
may be assessed with the Adult Attachment Interview (AAI)
[23], which addresses the individuals reports and memories
regarding early attachment experiences with parents. The AAI
yields classifications based mainly on the structural properties
of the individuals narrative rather than the content, especially
on the coherence of the narrative, and thus assesses state of
mind with respect to attachment [24,25]. Another approach to
assessing adult attachment relies on self-report questionnaires,
which address the individuals conscious attitudes and feelings
and style of relating with their current romantic partner
or other close personal relationship. The correlations between
the AAI and the attachment style questionnaires are
generally small, suggesting that they measure different aspects
of attachment [26,27].
Whereas the AAI yields the primary attachment classifica-
tions of secureautonomous, insecuredismissing, insecure
preoccupied, and unresolved [23,28], the self-report attach-
ment questionnaires either assign individuals to categories
of attachment style or measure the degree to which dimensions
of attachment style are present [29]. In a second-order factor
analysis, Brennan, Clark and Shaver [30] demonstrated that
the factors derived from all known self-report attachment
questionnaires form two higher-order factors representing the
two dimensions of attachment anxiety and attachment
avoidance. In recent years several researchers have questioned
whether categories are the best way to define individual
differences in attachment, as there is accumulating evidence
that the distinction between secure and insecure patterns of
attachment is more reliable and predictive than distinctions
between various types of insecurity [31]. Maunder and Hunter
[31], for example, have proposed a prototype-based model of
attachment, which reduces the boundaries between categories
and places individuals along a dimension of severity of
attachment insecurity that is determined by how strongly self-
report measures of attachment anxiety and attachment
avoidance are associated.
Although it is usual practice to code the AAI categorically,
Kobak [32] developed the AAI Q-sort that yields continuous
1259
measures of secure vs. anxious and deactivation vs. hyper-
activation, as well as for dismissing and preoccupied
attachment representations; however, the Q-sort does not
identify the unresolved category among the Main and
Goldwyn AAI classifications [28]. The hyperactivation and
deactivation dimensions correspond conceptually to the
attachment anxiety and avoidance dimensions assessed with
attachment style questionnaires [33]. Some empirical support
for coding AAI-related variation dimensionally was provided
by a taxometric investigation of the latent structure of the AAI;
the variation underlying secure vs. dismissing states of mind
was more consistent with a dimensional than a taxonic model
[34]. On the basis of this finding, Roisman, Fraley, and Belsky
[34] recommend that researchers use either the AAI Q-sort
in their empirical analyses or State of Mind scales, which
are continuous rating scales used by AAI coders to sort
participants into attachment categories. Waters, Treboux,
Fyffe, and Crowell [35] similarly describe advantages of
using the AAI State of Mind scales for research on attachment
development and stability.
1.1. Previous research on alexithymia and attachment
Most studies exploring associations between alexithymia
and attachment have assessed attachment styles with self-
report questionnaires; self-report scales were used to measure
alexithymia, usually the 20-item Toronto Alexithymia Scale
(TAS-20), which has three factor scales that assess the facets of
the alexithymia construct difficulty identifying feelings
(DIF), difficulty describing feelings (DDF), and externally
oriented thinking (EOT) [36,37]. The majority of the studies
were conducted with university student samples, but samples
of alcoholic inpatients, young men with mood symptoms, and
male parolees have also been investigated. In sum, all of the
studies found that alexithymia was associated with insecure
attachment styles dismissing/avoidant, and/or preoccupied,
and/or fearful avoidant styles although the various
categorical and dimensional questionnaires may label these
styles differently [3845]. Moreover, in a student sample,
attachment style dimensions significantly improved the
prediction of the TAS-20 score beyond that afforded by
anxiety, depression, the domains of the FFM of personality,
and temperament and character dimensions [43].
To our knowledge, only two studies have used the AAI to
explore relations between alexithymia and state of mind with
respect to attachment. In one study, 40 patients with systemic
lupus erythematosus were administered the AAI and classified
as secure, insecure (dismissing or entangled/preoccupied),
or unresolved; the secure patients had significantly lower TAS-
20 total scores and DDF factor scale scores than the insecure
and unresolved groups, but there were no differences on the
DIF and EOT factor scale scores [46]. The other study was
conducted with a sample comprised of 40 subjects (including
patients with idiopathic spasmodic torticollis and healthy
individuals); the AAI was scored with the AAI Q-sort, resulting
in dimensional scores for secure, dismissing, preoccupied, and
1260 G.J. Taylor et al. / Comprehensive Psychiatry 55 (2014) 12581268
deactivating participants [47]. The TAS-20 and its EOT
factor scale correlated negatively and significantly with the
secure dimension and positively and significantly with the
dismissing and deactivating dimensions; the DIF and DDF
factor scales did not correlate significantly with any of the
attachment dimensions.
1.2. Influence of alexithymia and attachment on
close relationships
On theoretical grounds, both attachment and alexithymia
are assumed to influence the quality of close relationships in
adulthood. Findings from several empirical studies support
this assumption, although the evidence linking attachment
and relationship functioning is primarily from studies that
assessed attachment styles rather than attachment states
of mind. For example, in a study with married couples,
relationship satisfaction was associated positively with a
secure attachment style in both husbands and wives,
negatively with an anxious style in wives, and negatively
with an avoidant style in men [48]. And in a study with couples
who had recently become parents for the first or second time,
insecure attachment was associated significantly with marital
dissatisfaction and was especially strong in second-time
parents with dismissingavoidant attachment styles [49]. In
other research with a sample of students who were currently or
recently in a romantic relationship, dimensional measures of
attachment anxiety and attachment avoidance correlated
negatively with a relationship quality index [50]. Interestingly,
the attachment style dimensions predicted relationship
quality better than the domains and facets of the FFM of
personality [50].
Whereas the above studies demonstrate an association
between self-reported attachment styles and the quality of adult
intimate relationships, studies that assessed state of mind with
respect to attachment found no association with self-reports
of marital satisfaction and couple communication [51] or with
self-reported perceptions of intimacy, love, and ambivalence
in the marital relationship [52]. Observations of interactions
between husbands and wives, however, revealed some
significant findings; secureautonomous husbands were in
more harmonious and less conflictual marriages than insecure
husbands [51], insecurepreoccupied wives expressed less
positive affect than secure wives, and insecuredismissing
wives engaged in more withdrawal than secure wives [52].
In a more recent study with 50 engaged couples, security
(measured with the AAI Q-sort) was associated with higher
levels of observed collaboration between partners in negoti-
ating mild conflict, but neither the security dimension, nor the
deactivation dimension of the AAI Q-sort was associated with
the self-reported emotional tone of their relationship [26].
Although the discrepancy between self-report and observa-
tional findings, and the lack of consistency with results
obtained in studies that assessed attachment styles, may be
attributed to different methods of measurement and to
differences in the constructs being measured, they suggest
that state of mind with respect to attachment may not be a
strong predictor of marital quality.
To investigate the influence of alexithymia on relationship
satisfaction, Yelsma and Marrow [53] administered the TAS-
20 to 66 married couples and assessed their marital satisfaction
with the Dyadic Adjustment Scale [54]. Wives difficulties
with identifying feelings negatively influenced their own and
their husbands marital satisfaction; husbands difficulties
describing their feelings negatively influenced their own and
their wives marital satisfaction; and husbands with an
externally oriented thinking style were less satisfied in their
marriages. In a study with a sample of university students,
all of whom were involved in a romantic relationship, the
TAS-20 and its three factor scales all correlated negatively
with measures of relational and sexual satisfaction [55]. Hesse
and Floyd [56] also found alexithymia to be inversely related
to the amount of affection one gave to their closest relationship
and how close they were to that person in a student sample.
1.3. The current study
Our first aim of the current study was to examine relations
between alexithymia and state of mind with respect to
attachment in a sample of healthy pregnant women. This was
a subsample of women who participated in earlier longitu-
dinal investigations of maternal and infant attachment
[57,58]. Although pregnant women are a highly-select
sample, we hypothesized that the level of alexithymia
would be higher in women classified as insecure than those
classified as secure, and that alexithymia would be related
negatively to coherence of mind, assessed with the AAI
Coherence of Mind scale, which is considered the single
best dimensional predictor of security vs insecurity [26].
Our second aim was to examine relations among alexithymia,
coherence of mind, perceived relationship adjustment, and
the domains of the FFM of personality. We hypothesized
that alexithymia would be a stronger predictor of coherence
of mind than the domains of the FFM. We hypothesized also
that alexithymia and the domains of the FFM would predict
perceived relationship adjustment.
2. Method
2.1. Participants
The participants were a subsample of a larger sample
described elsewhere [57,58]. In the larger sample, expectant
mothers were recruited during the second or third trimester
of pregnancy from prenatal classes at hospitals in a large
urban centre or provided by the public health department for
a longitudinal study of the first two years of life. A research
assistant visited each class and asked for volunteers to
complete the Attachment Screening Questionnaire (ASQ)
[59], the purpose of which was to increase the number of
women in the insecure attachment categories. Of the 680
mothers attending classes, 357 (52%) completed the ASQ.
 G.J. Taylor et al. / Comprehensive Psychiatry 55 (2014) 12581268
Based on their scores, 233 women were contacted and 139
(60%) of them agreed to participate in the study; this was a
large percentage given that the women were asked for a two-
year commitment for the longitudinal investigations, which
included two prenatal visits and four postnatal visits to the
lab [58]. As indicated in a report of an earlier investigation
with this sample, some women withdrew during prenatal
data collection and others before post-partum follow-up visits
[58]. Some of the mothers who withdrew did not complete
the AAI and the interviews of those who withdrew later were
not transcribed and scored. The women gave written voluntary
informed consent to their participation as approved by the
institutional research ethics board.
For the current investigation, we included only those
97 mothers with complete data on all relevant measures.
Independent samples t-tests and 2 tests were conducted to
compare the characteristics of participants included in the
current sample vs. those who did not complete all measures.
The results of these analyses showed that non-completers were
more likely to be unmarried ( 2 (1) = 10.59, p = .001) and to
have parents who divorced ( 2 (1) = 6.06, p = .014), relative
to those in the current sample. No other differences were
observed. The ethno-racial composition of the sample was:
Caucasian (74.2%); Asians (5.2%), AfricanCanadians
(2.1%), Hispanics (2.1%), First Nations Canadians (1%),
and other (14.4%). The mean age of the sample was
31.77 years, (SD = 3.65, range 2042 years); the mean years
of education was 15.73 (SD = 3.04, range 523 years of
school). The majority of the participants were married or in
a common-law relationship (97%); most were employed
(91.8%) and 79.4% reported an earned annual family income
exceeding CDN$50,000.
2.2. Measures
Alexithymia was assessed with the self-report 20-item
Toronto Alexithymia Scale (TAS-20), which is the most
widely and frequently-used measure of alexithymia; it is
well-validated and shows internal and retest reliability
[36,37]. Each item is rated on a five-point Likert scale
ranging from 1 (strongly disagree) to 5 (strongly agree).
Scores range from 20 to 100 with higher scores indicating
higher levels of alexithymia. Empirically established cut-off
scores may be used to identify high, moderate, and low
levels of alexithymia. The TAS-20 has three factor scales
that assess: (1) Difficulty identifying feelings and distin-
guishing them from the bodily sensations that accompany
states of emotional arousal (DIF) (7 items); (2) Difficulty
describing feelings to others (DDF) (5 items); and (3)
Externally-oriented style of thinking (EOT) (8 items).
There is evidence that the restricted imagination facet of
the alexithymia construct is measured indirectly by the EOT
factor [37,60].
The Attachment Screening Questionnaire (ASQ) is derived
from the Adult Attachment Questionnaire and consists of 18
statements about the respondents parents, relationship with
1261
each parent during childhood, and the impact of these
relationships on the persons development [59]. Each
statement is rated on a Likert scale ranging from 1 (strongly
agree) to 5 (strongly disagree). Aside from 2 filler items,
the scores on 8 items are added to provide a dismissing score
and the remaining 8 items provide a preoccupied score. The
scores are used to identify potential dismissing and preoccu-
pied participants.
The Adult Attachment Interview (AAI) is a semi-
structured interview with open-ended questions that ask the
respondent to recollect childhood relationships with attach-
ment figures, describe attachment-relevant experiences from
early childhood, and evaluate the impact of these experiences
on their development, current functioning, and parenting [61].
The interview, which takes approximately one hour to
complete, is tape-recorded, transcribed, and coded using
guidelines described in a manual [28]. Focusing on the
qualitative aspects of the narrative rather than factual
information, each transcript is rated on a series of 9-point
scales, which assess experiences with each attachment figure
(Experience scales) and current state of mind with respect
to those experiences (State of Mind scales). The principal
scale to assess overall state of mind with respect to adult
attachment is the Coherence of Mind (CohM) scale, which
is considered to predict, better than any other single score,
a subjects overall functioning insofar as it is related to
attachment [28]. CohM scores range from 1 to 9 and refer to
the degree to which respondents discussed and evaluated their
attachment-related experiences, including loss and trauma, in a
reasonably consistent manner, without gaps and defenses, and
gave specific, appropriate, and believable examples to support
their attachment experiences [27,62]. All transcripts used in
the current study had been coded in a previous study by a
trained coder (DB) who had passed the standard reliability test
at top level and established reliability with other laboratories;
the coder was masked to all other measures [58]. The women
received classifications of secureautonomous, insecure
dismissing, insecurepreoccupied, or unresolved with respect
to loss or abuse. Following the method used by other researchers
[63], for the purpose of this study unresolved women were
classified as insecure, regardless of their secondary classifica-
tion. To increase statistical power to the analyses, ratings on the
CohM scale were used as a continuous variable.
The Dyadic Adjustment Scale (DAS) is a 32-item scale
for assessing relationship quality and satisfaction among
married couples or similar dyads [54]. The scale has been
used in previous investigations of the influence of alex-
ithymia or attachment styles on perceived relationship
adjustment [48,49,53] and can be administered in self-report
or interview formats. The DAS has four subscales that
measure the respondents perception of consensus, satisfac-
tion, cohesion, and affectional expression in the relationship.
As in the previous investigations, we computed the total
score as an overall measure of relationship adjustment.
Scores of the two partners can be compared or examined
individually, with higher scores reflecting a higher level of
1262 G.J. Taylor et al. / Comprehensive Psychiatry 55 (2014) 12581268

adjustment. Internal consistency of the DAS has been Table 1

demonstrated [64]. Mean raw scores, standard deviations, and range of scores for the TAS-20,
NEO PI-R, AAI Coherence of Mind scale, and DAS.
The Revised NEO Personality Inventory (NEO PI-R) is a
widely-used instrument that was designed to assess the five Scale Range M SD
higher-order domains of the FFM of personality and also six TAS-20 Total 2370 42.22 10.32
lower-order facets nested within each of these five domains DIF factor scale 729 14.22 5.27
DDF factor scale 522 11.50 4.05
[65]. It is composed of 240 items presented in a 5-point
EOT factor scale 927 16.51 4.25
Likert format ranging from 1 (strongly agree) to 5 (strongly NEO PI-R Neuroticism 46146 86.36 19.33
disagree). There are two forms self-report and informant NEO PI-R Extraversion 68158 116.34 17.06
report the self-report version was used in the current study. NEO PI-R Openness 84156 119.18 17.38
Scores are computed for each domain (Neuroticism, NEO PI-R Agreeableness 97151 123.84 11.56
NEO PI-R Conscientiousness 75160 121.19 19.08
Extraversion, Openness to Experience, Agreeableness,
AAI Coherence of Mind 1.508.00 4.18 1.52
and Conscientiousness) and for the separate facets in each DAS 81144 116.72 10.55
domain. Due to statistical power restriction we used only
TAS-20 = 20-Item Toronto Alexithymia Scale; DIF = Difficulty Identifying
domain level scale scores. Feelings; DDF = Difficulty Describing Feelings; EOT = Externally Oriented
Thinking; NEO PI-R = Revised NEO Personality Inventory; AAI = Adult
2.3. Procedure Attachment Interview; DAS = Dyadic Adjustment Scale.

The TAS-20, DAS, and NEO PI-R were administered

at a prenatal visit. The AAI was administered at a second
prenatal visit.
2.4. Statistical analyses
TAS-20 scores were compared between participants
classified as secureautonomous on the AAI and those
classified as insecuredismissing, insecurepreoccupied, or
insecureunresolved. Relations between the TAS-20 and the
DAS, NEO PI-R domains, and CohM scale were examined
using Pearson product moment correlations. Regression
analyses were conducted to compare the TAS-20 total score
with the three TAS-20 factor scale scores in predicting CohM
scores. In addition, regression analyses were conducted to
determine how the TAS-20 and the NEO PI-R compare in
predicting CohM scores and DAS scores.
with the CohM scale. The TAS-20 and its DIF and DDF
factor scales also correlated negatively with the DAS, but the
EOT factor was unrelated to the DAS. The CohM scale did
not correlate significantly with the DAS.
In Table 4 the pattern of correlations among the TAS-20, the
NEO PI-R domains, the CohM scale, and the DAS is displayed.
The TAS-20 correlated positively with the Neuroticism domain
and negatively with the Extraversion, Openness to Experience,
and Conscientiousness domains of the NEO PI-R. Conversely,
the DAS correlated negatively with the Neuroticism domain
and positively with the Extraversion, Openness to Experience,
and Conscientiousness domains of the NEO PI-R. The
Agreeableness domain did not correlate significantly with the
TAS-20 or the DAS. The CohM scale did not correlate
significantly with any of the domains of the NEO PI-R.

3.1. Regression analyses

3. Results
The results of the regression analyses examining alexithymia
Mean scores and standard deviations for the TAS-20, as a predictor of coherence of mind are presented in Table 5. In
NEO PI-R, CohM scale, and DAS are displayed in Table 1. the first analysis (Model 1) we entered the three TAS-20 factor
Of the total sample, 79 (81.4%) women scored in the low scales as a block; in the second analysis (Model 2) we entered
alexithymia range (b52) of the TAS-20, 12 women (12.4%)
in the moderate range (52-60), and 6 women (6.2%) in the
Table 2
high range (N60). Based on coding of the AAI transcripts,
Differences in mean TAS-20 total and factor scale scores between insecure
45 women were classified as secureautonomous, 13 women (dismissing, preoccupied, and unresolved) and secure AAI categories
as insecuredismissing, 15 as insecurepreoccupied, and of attachment.
24 as insecureunresolved; the last three classifications were Insecure (n = 52) Secure (n = 45) t(95)
combined to form an insecure group. The range of scores
M SD M SD
and the mean score for the CohM scale indicate adequate
variability for this variable. TAS-20 Total 44.79 11.00 39.24 8.67 3.16
TAS-20 DIF 15.56 5.53 12.67 4.54 3.32
As shown in Table 2, the insecure group of women scored
TAS-20 DDF 11.98 4.10 10.93 3.97 1.05
significantly higher than the secure group of women on the TAS-20 EOT 17.25 4.36 15.64 4.00 1.21
total TAS-20 and on its DIF factor scale. Table 3 displays the
TAS-20 = Toronto Alexithymia Scale; DIF = Difficulty Identifying Feelings;
pattern of correlations among the TAS-20 and its three factor DDF = Difficulty Describing Feelings; EOT = Externally Oriented Thinking;
scales, the CohM scale, and the DAS. The TAS-20 and its AAI = Adult Attachment Interview.
three factor scales all correlated significantly and negatively p b .01.
 G.J. Taylor et al. / Comprehensive Psychiatry 55 (2014) 12581268 1263

Table 3 order, the Openness to Experience domain of the NEO PI-R

Inter-correlations among the TAS-20, DAS, and AAI Coherence of Mind
scale.
1 2 3 4
1. TAS-20 Total
2. TAS-20 DIF .83***
3. TAS-20 DDF .83*** .62***
4. TAS-20 EOT .61*** .17 .29**
5. DAS .27** .27** .23* .11
6. AAI Coherence of Mind .32** .28** .21* .21* .15
DAS = Dyadic Adjustment Scale; TAS-20 = Toronto Alexithymia Scale;
DIF = Difficulty Identifying Feelings; DDF = Difficulty Describing Feelings;
EOT = Externally Oriented Thinking; AAI = Adult Attachment Interview.
* p b .05, ** p b .01, *** p b .001.
the total TAS-20. The total TAS-20 was a significant negative
predictor of CohM scores ( = .32; p = .002; R 2 = .10). The
individual factor scales of the TAS-20 on their own did not
significantly predict CohM scores.
To determine how the TAS-20 and the five domains
of the NEO PI-R compare in predicting CohM scores, we
subsequently performed two hierarchical regression analy-
ses. In the first analysis (Model 1) we entered the TAS-20
in the first step, and block entered the domains of the NEO
PI-R in the second step. In the second analysis (Model 2) we
reversed the order of variable entry and entered the block of
NEO PI-R domains first, and the TAS-20 second. As shown
in Table 6, the TAS-20 significantly predicted CohM scores
whether entered in Step 1 or Step 2; the domain scales of the
NEO PI-R did not contribute to the prediction. A similar
procedure was used to compare the TAS-20 and the five
domains of the NEO PI-R in predicting total scores on the
DAS. In the first analysis (Model 1) in which the TAS-20
was entered in Step 1, the alexithymia scores emerged as
a significant negative predictor of DAS scores ( = .27;
p = .007); however, when the domain scales of the NEO PI-R
were entered in the second step, there was an increase in
predictive power ( R 2 = .15; F = 3.54; p = .006), which
was accounted for primarily by the Openness to Experience
domain ( = .27; p = .020) (see Table 7). In the second
analysis (Model 2) with the variables entered in the reverse
was a positive predictor of DAS scores ( = .27; p = .008;
R 2 = .23); the TAS-20 scores entered in Step 2 did not
5 significantly increase the predictive power.
4. Discussion
Using a sample of healthy pregnant women, this study
extended previously published studies examining relations
between alexithymia and attachment, as well as studies that
have investigated the associations of one or other of these
constructs with perceived relationship adjustment or the
domains of the FFM of personality. Our finding that women
classified as insecure on the AAI were more alexithymic than
women classified as secure is consistent not only with
findings from two previous studies that measured attach-
ment with the AAI [46,47], but also with multiple studies
that assessed attachment styles with self-report question-
naires [3845]. In addition, our study is the first to examine
relations between alexithymia and coherence of mind,
which is rated as a continuous variable and is considered
theoretically and empirically the single best indicator of
AAI security [26]. In our sample of women, TAS-20 total
scores correlated negatively with the CohM scale, and in
the regression analyses also predicted coherence of mind
scores, whereas the five domains of personality measured
with the NEO PI-R did not correlate with coherence of mind
or add significantly to the prediction.
The absence of significant associations between coher-
ence of mind and the domains of the FFM of personality
is interesting as previous studies have reported modest or
moderate relations between the Big Five personality
domains and measures of attachment styles. For example,
in an early study with a university student sample, students
who were securely attached were found to be less neurotic
and more extraverted than insecurely attached students, and
also more agreeable and slightly more conscientious than
insecureavoidant students [66]. In a later study also conducted
with a student sample, insecure attachment styles were related
positively to neuroticism and negatively to extraversion

Table 4
Correlations of the NEO PI-R domains with the TAS-20, AAI Coherence of Mind scale, and Dyadic Adjustment Scale.
1 2 3 4 5 6 7
1. TAS-20 Total
2. NEO PI-R Neuroticism .42***
3. NEO PI-R Extraversion .25** .36***
4. NEO PI-R Openness .38*** .06 .37***
5. NEO PI-R Agreeableness .03 .10 .04 .12
6. NEO PI-R Conscientiousness .28** .36*** .11 .10 .02
7. AAI Coherence of Mind .32** .11 .05 .19 .00 .04
8. DAS .27** .32** .30** .32** .13 .21* .15
TAS-20 = 20-item Toronto Alexithymia Scale; NEO PI-R = Revised NEO Personality Inventory; AAI = Adult Attachment Interview; DAS = Dyadic
Adjustment Scale.
* p b .05, ** p b .01, *** p b .001.
1264 G.J. Taylor et al. / Comprehensive Psychiatry 55 (2014) 12581268

Table 5 questionnaire were extraversion and neuroticism, respectively;

Multiple regression analyses predicting AAI Coherence of Mind scores with the deactivating dimension of the AAI Q-sort was associated
TAS-20 total scores and factor scale scores.
negatively with neuroticism and to a lesser extent openness
Scale B SEB 95% C.I. R2 F to experience, and marginally with extraversion, whereas the
Model 1 .11 3.73* Q-sort security dimension was marginally associated with
TAS-20 DIF 0.07 0.04 .25 [0.14, 0.00] conscientiousness and extraversion [26]. In a separate sample
TAS-20 DDF 0.00 0.05 .01 [0.10, 0.09]
of engaged couples, however, none of the five dimensions
TAS-20 EOT 0.06 0.04 .17 [0.13, 0.01]
Model 2 .10 10.43** of personality were uniquely associated with the AAI Q-sort
TAS-20 Total 0.05 0.01 .32** [0.08, 0.02] security or deactivating dimensions [26]; this finding is
TAS-20 = Toronto Alexithymia Scale; DIF = Difficulty Identifying Feelings;
consistent with the absence of significant associations
DDF = Difficulty Describing Feelings; EOT = Externally Oriented Thinking; between the FFM personality domains and AAI coherence
AAI = Adult Attachment Interview. of mind in our sample of pregnant women. In contrast to
* p b .05. ** p b .01. the different findings obtained with self-report vs. state
of mind measures of attachment, it is noteworthy that
and conscientiousness, but were unrelated to agreeableness; alexithymia, which correlates in predictable ways with the
students with an insecureavoidant style were less open to domains of the FFM of personality [6], is associated with
experience than secure students [50]. Moreover, in regression insecure attachment measured by both the AAI and self-report
analyses, neuroticism and conscientiousness added significant- adult attachment questionnaires.
ly to relationship status (being single or in a relationship) in In the current study, as in several previous studies [6],
predicting anxious attachment, and extraversion and conscien- alexithymia measured with the TAS-20 was associated
tiousness added significantly to relationship status in predicting positively with neuroticism, negatively with extraversion,
avoidant attachment. Noftle and Shaver [50] summarized many openness to experience, and conscientiousness, and was
other studies that examined relations between attachment styles unrelated to agreeableness. In addition, both alexithymia
and the Big Five personality dimensions; in most studies, and neuroticism were associated negatively with relationship
secure attachment was related negatively to neuroticism, and adjustment, whereas extraversion, openness to experience,
positively to extraversion, agreeableness, and conscientious- and conscientiousness were associated positively with rela-
ness, whereas insecure attachment was related positively to tionship adjustment. Coherence of mind, on the other hand,
neuroticism, and negatively to extraversion and agreeableness. was unrelated to relationship adjustment. In regression
In a more recent study, both the AAI (scored with the Q-sort) analyses, the FFM of personality was stronger than alexithy-
and a self-report measure of attachment style were administered mia in predicting relationship adjustment with the openness to
to a sample of undergraduate university students; in regression experience domain explaining 23% of the variance in DAS
models, the strongest personality predictors of scores on the scores. That is, women who scored high in openness reported
avoidance and anxiety dimensions of the attachment style being better adjusted in their marital or other close relationship.

Table 6
Multiple regression analyses predicting coherence of mind with alexithymia and the domains of the FFM of personality.
Scale B SEB 95% C.I. R2 F R2 F
Model 1
Step 1 .10 10.43**
TAS-20 Total 0.05 .01 .32** [0.08, 0.02]
Step 2 .11 1.82 .01 0.19
Neuroticism 0.00 .01 .02 [0.02, 0.02]
Extraversion 0.01 .01 .06 [0.03, 0.02]
Openness 0.01 .01 .09 [0.01, 0.03]
Agreeableness 0.00 .01 .03 [0.03, 0.02]
Conscientiousness 0.00 .01 .04 [0.02, 0.01]

Model 2
Step 1 .05 0.96
Neuroticism 0.01 0.01 .12 [0.03, 0.01]
Extraversion 0.01 0.01 .07 [0.03, 0.02]
Openness 0.02 0.01 .21 [0.00, 0.04]
Agreeableness 0.01 0.01 .04 [0.03, 0.02]
Conscientiousness 0.00 0.01 .02 [0.02, 0.02]
Step 2 .11 1.82 .06 5.91*
TAS-20 Total 0.04 0.02 .30* [0.08, 0.01]
TAS-20 = 20-Item Toronto Alexithymia Scale; FFM = five-factor model.
* p b .05. ** p b .01.
 G.J. Taylor et al. / Comprehensive Psychiatry 55 (2014) 12581268 1265

Table 7
Multiple regression analyses predicting relationship adjustment with alexithymia and the domains of the FFM of personality.
Scale B SEB 95% C.I. R2 F R2 F
Model 1
Step 1 .08 7.66**
TAS-20 0.28 .10 .27** [0.48, 0.08]
Step 2 .23 4.40** .15 3.54**
Neuroticism 0.11 .06 .19 [0.23, 0.02]
Extraversion 0.07 .07 .11 [0.06, 0.20]
Openness 0.16 .07 .27* [0.03, 0.30]
Agreeableness 0.07 .09 .08 [0.10, 0.24]
Conscientiousness 0.08 .06 .15 [0.03, 0.20]

Model 2
Step 1 .23 5.33***
Neuroticism 0.11 .06 .20 [0.23, 0.01]
Extraversion 0.07 .07 .11 [0.06, 0.20]
Openness 0.17 .06 .27** [0.04, 0.29]
Agreeableness 0.07 .09 .08 [0.10, 0.24]
Conscientiousness 0.08 .06 .15 [0.03, 0.19]
Step 2 .23 4.40** .00 0.03
TAS-20 0.02 .12 .02 [0.25, 0.21]
TAS-20 = 20-Item Toronto Alexithymia Scale; FFM = five-factor model.
* p b .05. ** p b .01.

These women may be considered low in alexithymia since,
as noted earlier, there is some conceptual overlap of the
alexithymia construct and the openness to experience domain
[6]. Indeed, the facet scales of the openness domain measured
by the NEO PI-R include openness to fantasy and receptivity
to ones own inner feelings [65], which have been shown to
correlate negatively with the TAS-20 in Canadian university
student and community samples [6,37].
Our results may be compared with findings from several
other studies. For example, with a sample of French Canadian
couples, Bouchard, Lussier, and Sabourin [67] conducted
regression analyses with the DAS total score as the criterion
variable and scores of the domains of the FFM of personality as
predictors; neuroticism was the strongest predictor of womens
marital adjustment explaining 16% of variation, with agree-
ableness explaining another 1% of the overall variation. For the
men, however, neuroticism explained only 6% of the variation
in DAS scores; openness, agreeableness, and conscientiousness
added another 5%.
The absence of a significant relation between coherence
of mind and relationship adjustment in our study is
consistent with previous studies in which AAI categorical
classifications were unrelated to self-report measures of
marital quality [51,52]; however, such findings contrast with
Noftle and Shavers [50] finding that dimensional measures
of attachment anxiety and attachment avoidance predicted
relationship quality, whereas none of the Big Five domains
of personality made unique, significant contributions to
account for variance. The different findings are most likely
explained by the distinct nature of the constructs being
measured. As noted earlier, the AAI assesses state of mind
with respect to attachment, whereas self-report measures
of attachment style assess an individuals conscious attitudes
and feelings regarding closeness in their current adult
attachment relationship. And while one would expect
measures of attachment styles to predict some of the ways
adults relate to each other in their intimate relationships,
as Shaver, Belsky, and Brennan [27] point out, the AAI was
originally designed to predict a childs quality of attachment
to his or her parent based on the parents state of mind with
respect to attachment (p. 26). As noted by others, the quality
of adult attachment relationships is not explained solely by
the adults history of relationships with parents, but involves
other qualities including commitment, communication, sexual
attraction, conflict resolution strategies, loneliness, and patterns
of self-disclosure [25,27].
4.1. Limitations and future research
The main limitations of the study pertain to the nature of
the sample. Given that the participants were, overall, young,
well-educated women at a special time in their lives as
they anticipated giving birth to a baby, the findings may not
generalize to older or less-educated women, to women who
are not pregnant, or to men. Questions may also be raised
about applying the findings to highly insecure women since
the non-completers in the study were more likely to be
unmarried and to have parents who were divorced, and therefore
likely to be insecurely attached; yet 54% of the completers were
classified as insecure on the AAI. Nonetheless, the findings need
to be replicated with samples of men and non-pregnant women
with a wide range of ages and attachment classifications.
Despite the selective nature of the sample, pregnant
women are of considerable interest to psychiatry given their
risk for postpartum depression, and evidence from develop-
mental research that expectant mothers attachment
1266 G.J. Taylor et al. / Comprehensive Psychiatry 55 (2014) 12581268
representations and mentalizing ability influence the orga-
nization of infantmother attachment at one year of age and
the mothers ability to read the emotional states of their
infants [68]. Depressed mothers and mothers with insecure
attachment and alexithymia are liable to have difficulty
attending to their infants attachment needs and responding
in ways that foster the development of mentalizing and affect-
regulating capacities in their children [14,17,18]. Moreover,
there is evidence that maternal depression during infancy
contributes to the prediction of depressive symptoms in
children and adolescents [69].
It has been argued that individuals with higher levels of
alexithymia may be unable to accurately evaluate their ability
to identify and describe subjective feelings. A potential
limitation of our study, therefore, was the use of a self-report
scale to assess alexithymia. The percentage of pregnant
women who scored in the high range of the TAS-20 (6.2%),
however, was quite small, although identical to the percentage
reported for women in a recent study of married couples in
the U.S. [70]. Moreover, at the time our data were collected
a multi-method approach to measuring alexithymia was not
possible as non-self-report measures of alexithymia were
either not fully validated or not yet developed. Future studies
might use the Toronto Structured Interview for Alexithymia
[60,71] in combination with the TAS-20. Another limitation
was our reliance on the self-report DAS to assess the
pregnant womens relationship satisfaction and other aspects
of relational functioning with their spouse or intimate partner.
Given that two earlier studies investigating associations
between attachment states of mind and marital functioning
reported some differences between findings based on self-
reports and those based on observations of couples
interactions [51,52], future studies exploring associations
between coherence of mind and relationship adjustment
should also employ multiple methods of assessment. An
additional limitation of our study is that we did not have the
womens partners reports of the quality of their relationship. It
would be preferable in future studies to assess both partners in
the relationship as there is some evidence that gender may play
a role in how alexithymia may adversely affect marital quality
[70], and that an individuals marital adjustment may be
influenced by the attachment status of the spouse [51,52].
Another limitation is that we were not able to examine the
facet scales of the NEO PI-R in predicting coherence of
mind and relationship adjustment because of the relatively
small sample size and lack of statistical power; this might
be done in future studies with larger samples and more
statistical power.
4.2. Conclusion
As anticipated, alexithymia predicted state of mind with
respect to attachment, whereas the domains of the FFM of
personality did not add significantly to the prediction. This
finding is not surprising since alexithymia is thought to
reflect a deficit in the cognitive processing and regulation
of emotions, capacities that develop optimally only when
children have secure attachment relationships with their
parents [14]. In contrast, the FFM is a descriptive model of
personality structure that emerged from a lexical tradition;
major personality traits, like temperament, are presumed
to be biologically-based [72]. Although previous studies
have found consistent and meaningful associations be-
tween attachment style questionnaires and personality trait
measures [50], attachment style questionnaires assess the
level of security in an adults current intimate relationship
rather than the coherence of discourse and state of mind
regarding childhood attachment-related experiences [26].
Thus, although there is now evidence that alexithymia is
associated with insecure attachment measured dimension-
ally by both the AAI and attachment style questionnaires,
these associations cannot be assumed to have the same
meaning. A difference in meaning is further suggested by
the finding in the current study that perceived relationship
adjustment was unrelated to attachment state of mind
assessed with the CohM scale, whereas two previous
studies [48,49] reported associations between marital satisfac-
tion and attachment dimensions measured with attachment
style questionnaires.
Alexithymia may be rooted in early childhood
experiences, but difficulties in identifying and commu-
nicating feelings undoubtedly affect the quality of adult
relationships, particularly with a spouse, as implied by
the negative correlations between the TAS-20 and its
DIF and DDF factor scales and the DAS. As hypothe-
sized, relationship adjustment was also influenced by
personality traits, with the openness to experience
domain of the FFM emerging as the strongest predictor
for our sample.
Acknowledgment
This research was supported by funds from the
Social Sciences and Humanities Research Council of Canada
awarded to Leslie Atkinson, and funds from the Ontario
Mental Health Foundation awarded to Susan Goldberg and
Diane Benoit. We are indebted to Susan Goldberg, one
of the major contributors to the original investigations, who
passed away shortly after they were completed, but whose
influence is present in subsequent papers.
References
[1] Taylor GJ, Bagby RM. The alexithymia personality dimension. In: &
Widiger TA, editor. The Oxford handbook of personality disorders.
New York: Oxford University Press; 2012. p. 648-73.
[2] Sifneos PE. Affect deficit and alexithymia. New Trends Exp Clin
Psychiatry 1994;10:193-5.
[3] Taylor GJ, Bagby RM, Parker JDA. Disorders of affect regulation:
alexithymia in medical and psychiatric illness. Cambridge: Cambridge
University Press; 1997.
[4] Nemiah JC, Sifneos PE. Affect and fantasy in patients with
psychosomatic disorders. In: & Hill OW, editor. Modern trends
 G.J. Taylor et al. / Comprehensive Psychiatry 55 (2014) 12581268
in psychosomatic medicine, vol. 2. London: Butterworths; 1970.
p. 26-34.
[5] Nemiah JC, Freyberger H, Sifneos PE. Alexithymia: a view of the
psychosomatic process. In: & Hill OW, editor. Modern trends
in psychosomatic medicine, vol. 3. London: Butterworths; 1976.
p. 430-9.
[6] Taylor GJ, Bagby RM. Alexithymia and the five-factor model of
personality. In: Widiger TA, & Costa Jr PT, editors. Personality
disorders and the five factor model of personality. Washington, DC:
American Psychological Association; 2013. p. 193-207.
[7] Jrgensen MM, Zachariae R, Skytthe A, Kyvik K. Genetic
and environmental factors in alexithymia: a population-based study
of 8,785 Danish twin pairs. Psychother Psychosom 2007;76:369-75.
[8] Picardi A, Fagnani C, Gigantesco A, Toccaceli V, Lega I, Stazi MA.
Genetic influences on alexithymia and their relationship with depressive
symptoms. J Psychosom Res 2011;71:256-63.
[9] Aust S, Hrtwig EA, Heuser I, Bajbouj M. The role of early emotional
neglect in alexithymia. Psychol Trauma: Theory Res Pract Policy
2013;5:225-32.
[10] Zlotnick C, Mattia JI, Zimmerman M. The relationship between
posttraumatic stress disorder, childhood trauma and alexithymia in an
outpatient sample. J Trauma Stress 2001;14:177-88.
[11] Goldsmith RE, Freyd JJ. Awareness for emotional abuse. J Emot
Abuse 2005;5:95-123.
[12] Taylor GJ, Bagby RM. Psychoanalysis and empirical research: the
example of alexithymia. J Am Psychoanal Assoc 2013;61:99-133.
[13] Bradley SJ. Affect regulation and the development of psychopathology.
New York: Guilford Press; 2000.
[14] Fonagy P, Gergely G, Jurist EL, Target M. Affect regulation,
mentalization, and the development of the self. New York: Other
Press; 2002.
[15] Cassidy J. Emotion regulation: influences of attachment relationships.
Monogr Soc Res Child Dev 1994;59:228-49.
[16] Fonagy P, Target M. Attachment and reflective function: their role in
self-organization. Dev Psychopathol 1997;9:679-700.
[17] Meins E, Fernyhough C, Russell J. Security of attachment as a
predictor of symbolic and mentalizing abilities: a longitudinal study.
Soc Dev 1998;7:1-24.
[18] Lemche E, Klann-Delius G, Koch R, Joraschky P. Mentalizing
language development in a longitudinal attachment sample: implications
for alexithymia. Psychother Psychosom 2004;73:366-74.
[19] Malatesta CZ. The role of emotions in the development and
organization of personality. In: & Thompson RA, editor. Nebraska
symposium on motivation. Socioemotional developmentLincoln:
University of Nebraska Press; 1990. p. 1-56.
[20] Slade A, Aber JL. Attachment, drives, and development: conflicts and
convergences theory. In: Barron JW, Eagle MN, & Wolitzky DL,
editors. Interface of psychoanalysis and psychology. Washington, DC:
American Psychological Association; 1992. p. 154-85.
[21] Bowlby J. Attachment and loss. Separation: anxiety and anger, vol. II.
New York: Basic Books; 1973.
[22] Waters E, Merrick S, Treboux D, Crowell J, Albersheim I. Attachment
security in infancy and early adulthood: a twenty year longitudinal
study. Child Dev 2000;71:684-9.
[23] Hesse E. The Adult Attachment Interview. Historical and current
perspectives. In: Cassidy J, & Shaver PR, editors. Handbook of attachment:
theory, research and clinical applications. New York: Guilford Press; 1999.
p. 395-433.
[24] Eagle MN. Attachment and psychoanalysis. Theory, research, and
clinical implications. New York: Guilford Press; 2013.
[25] Jacobvitz D, Curran M, Moller N. Measurement of adult attachment:
the place of self-report and interview methodologies. Attach Hum Dev
2002;4:207-15.
[26] Roisman GI, Holland A, Fortuna K, Fraley RC, Clausell E, Clarke
A. The Adult Attachment Interview and self-reports of attachment
style: an empirical rapprochement. J Pers Soc Psychol
2007;92:678-97.
1267
[27] Shaver PR, Belsky J, Brennan KA. The Adult Attachment Interview
and self-reports of romantic attachment: associations across domains
and methods. Pers Relationships 2000;7:25-43.
[28] Main M, Goldwyn R. Adult attachment scoring and classification
systems. Unpublished manuscript. Department of Psychology,
University of California, Berkeley; 1994.
[29] Ravitz P, Maunder R, Hunter J, Sthankiya B, Lancee W.
Adult attachment measures: a 25-year review. J Psychosom Res
2010;69:419-32.
[30] Brennan KA, Clark CL, Shaver PR. Self-report measurement
of adult romantic attachment: an integrative overview. In: Simpson
JA, & Rholes WS, editors. Attachment theory and close relationships.
New York: Guilford Press; 1998. p. 46-76.
[31] Maunder RG, Hunter JJ. A prototype-based model of adult attachment
for clinicians. Psychodyn Psychiatry 2012;40:549-74.
[32] Kobak RR. The Adult Attachment Interview Q-set. Unpublished
manuscript, University of Delaware; 1993.
[33] Shaver PR, Mikulincer M. Adult attachment strategies and the
regulation of emotion. In: & Gross JJ, editor. Handbook of emotion
regulation. New York: Guilford Press; 2007. p. 446-65.
[34] Roisman GI, Fraley RC, Belsky J. A taxometric study of the Adult
Attachment Interview. Dev Psychol 2007;43:675-86.
[35] Waters E, Treboux D, Fyffe C, Crowell J. Scoring secure versus
insecure and dismissing versus preoccupied attachment as continuous
variables: discriminant analysis using AAI state of mind scales.
Unpublished manuscript. Departments of psychology and psychiatry,
SUNY Stony Brook, NY; 2013.
[36] Bagby RM, Parker JDA, Taylor GJ. The twenty-item Toronto
Alexithymia Scale I. Item selection and cross-validation of the
factor structure. J Psychosom Res 1994;38:23-32.
[37] Bagby RM, Taylor GJ, Parker JDA. The twenty-item Toronto
Alexithymia Scale II. Convergent, discriminant, and concurrent
validity. J Psychosom Res 1994;38:33-40.
[38] Bekendam CC. Dimensions of emotional intelligence: attachment,
affect regulation, alexithymia and empathy. Doctoral dissertation.
Santa Barbara, CA: The Fielding Institute; 1997.
[39] Bekker MHJ, Bachrach N, Croon MA. The relationships of antisocial
behaviour with attachment styles, autonomy-connectedness, and
alexithymia. J Clin Psychol 2007;63:507-27.
[40] De Rick A, Vanheule S. The relationship between perceived parenting,
adult attachment style and alexithymia in alcoholic inpatients. Addict
Behav 2006;31:1265-70.
[41] Meins E, Harris-Waller J, Lloyd A. Understanding alexithymia:
associations with peer attachment style and mind-mindedness. Personal
Individ Differ 2008;45:146-52.
[42] Montebarocci O, Codispoti M, Baldaro B, Rossi N. Adult attachment
and alexithymia. Personal Individ Differ 2004;36:499-507.
[43] Picardi A, Toni A, Caroppo E. Stability of alexithymia and its
relationships with the big five factors, temperament, character, and
attachment style. Psychother Psychosom 2005;74:371-8.
[44] Troisi A, D'Argenio A, Peracchio F, Petti P. Insecure attachment and
alexithymia in young men with mood symptoms. J Nerv Ment Dis
2001;189:311-6.
[45] Wearden A, Lamberton N, Crook N, Walsh V. Adult attachment,
alexithymia, and symptom reporting. An extension to the four category
model of attachment. J Psychosom Res 2005;58:279-88.
[46] Barbasio C, Granieri A. Emotion regulation and mental representation
of attachment in patients with systemic lupus erythematosus. J Nerv
Ment Dis 2013;201:304-10.
[47] Scheidt CE, Waller E, Schnock C, Becker-Stoll F, Zimmerman P,
Lcking CH, et al. Alexithymia and attachment representation in
idiopathic spasmodic torticollis. J Nerv Ment Dis 1999;187:47-52.
[48] Scott RL, Cordova JV. The influence of adult attachment styles on
the association between marital adjustment and depressive symptoms.
J Fam Psychol 2002;16:199-208.
[49] Mller K, Hwang CP, Wickberg B. Romantic attachment, parenthood
and marital satisfaction. J Reprod Infant Psychol 2006;24:233-40.
1268 G.J. Taylor et al. / Comprehensive Psychiatry 55 (2014) 12581268
[50] Noftle EE, Shaver PR. Attachment dimensions and the big five
personality traits: associations and comparative ability to predict
relationship quality. J Res Pers 2006;40:179-208.
[51] Cohn DA, Silver DH, Cowan CP, Cowan PA, Pearson J. Working
models of childhood attachment and couple relationships. J Fam Issues
1992;13:432-49.
[52] Paley B, Cox MJ, Burchinal MR, Payne CC. Attachment and marital
functioning: comparison of spouses with continuous-secure, earned-
secure, dismissing, and preoccupied attachment stances. J Fam Psychol
1999;13:580-97.
[53] Yelsma P, Marrow S. An examination of couples difficulties with
emotional expressiveness and their marital satisfaction. J Fam
Commun 2003;3:41-62.
[54] Spanier GB. Measuring dyadic adjustment: new scales for assessing the
quality of marriage and similar dyads. J Marriage Fam 1979;38:15-28.
[55] Humphreys TP, Wood LM, Parker JDA. Alexithymia and satisfaction
in intimate relationships. Personal Individ Differ 2009;46:43-7.
[56] Hesse C, Floyd K. Affectionate experience mediates the effects
of alexithymia on mental health and interpersonal relationships. J Soc
Pers Relat 2008;5:793-810.
[57] Atkinson L, Goldberg S, Raval V, Pederson D, Benoit D, Moran G,
et al. On the relation between maternal state of mind and sensitivity
in the prediction of infant attachment security. Dev Psychol
2005;41:42-53.
[58] Raval V, Goldberg S, Atkinson L, Benoit D, Myhal N, Poulton L, et al.
Maternal attachment, maternal responsiveness and infant attachment.
Infant Behav Dev 2001;24:281-304.
[59] Benoit D, Parker KCH. Attachment Screening Questionnaire (ASQ
1.0). Toronto, Ontario: Department of psychiatry research, Hospital for
Sick Children; 1994.
[60] Grabe HJ, Lbel S, Dittrich D, Bagby RM, Taylor GJ, Quilty LC, et al.
The German version of the Toronto Structured Interview for Alexithymia:
factor structure, reliability, and concurrent validity in a psychiatric patient
sample. Compr Psychiatry 2009;50:424-30.
[61] George C, Kaplan N, Main M. Adult Attachment Interview protocol. 2nd ed.
Unpublished manuscript. University of California at Berkeley; 1985.
[62] Busch AL, Lieberman AF. Mothers Adult Attachment Interview
ratings predict preschool IQ following domestic violence exposure.
Attach Hum Dev 2010;12:505-27.
[63] Roisman GI, Madsen SD, Hennighausen KH, Sroufe LA, Collins WA.
The coherence of dyadic behavior across parentchild and romantic
relationships as mediated by the internalized representation of experience.
Attach Hum Dev 2001;3:156-72.
[64] South SC, Krueger RF, Iacono WG. Factorial invariance of the Dyadic
Adjustment Scale across gender. Psychol Assess 2009;21:622-8.
[65] Costa Jr PT, McCrae RR. Revised NEO Personality Inventory (NEO-PI-R)
and NEO Five- Factor Inventory (NEO-FFI) professional manual. Odessa,
FL: Psychological Assessment Resources, Inc.; 1992.
[66] Shaver PR, Brennan KA. Attachment styles and the big five
personality traits: their connections with each other and with romantic
relationship outcomes. Pers Soc Psychol Bull 1992;18:536-45.
[67] Bouchard G, Lussier Y, Sabourin S. Personality and marital
adjustment: utility of the five-factor model of personality. J Marriage
Fam 1999;61:651-60.
[68] Arnott B, Meins E. Links between ante-natal attachment representa-
tions, postnatal mind- mindedness, and infant attachment security:
a preliminary study of mothers and fathers. Bull Menninger Clin
2007;71:132-49.
[69] Bureau J-F, Easterbrooks A, Lyons-Ruth K. Maternal depressive symptoms
in infancy: unique contributions to childrens depressive symptoms in
childhood and adolescence. Dev Psychopathol 2009;21:519-37.
[70] Frye-Cox NE, Hesse CR. Alexithymia and marital quality: the
mediating roles of loneliness and intimate communication. J Fam Psychol
2013;27:203-11.
[71] Bagby RM, Taylor GJ, Parker JDA, Dickens SE. The development of
the Toronto Structured Interview for Alexithymia: item selection,
factor structure, reliability and concurrent validity. Psychother
Psychosom 2006;75:25-39.
[72] McCrae RR, Costa Jr PT. Introduction to the empirical and theoretical status
of the five- factor model of personality traits. In: Widiger TA, & Costa Jr PT,
editors. Personality disorders and the five factor model of personality.
Washington, DC: American Psychological Association; 2013. p. 15-27.