The Impact of Alexithymia on Empathic Ability In

Home , Alexithymia, Empathic accuracy

THE IMPACT OF ALEXITHYMIA ON

EMPATHIC ABILITY IN SCHIZOPHRENIA

A dissertation submitted

to Kent State University in partial

fulfillment of the requirements for the

degree of Doctor of Philosophy

Marielle Divilbiss

August 2011

Dissertation written by

Marielle Divilbiss

B.A., DePaul University, 2007

M.A., Kent State University, 2009

Ph.D., Kent State University, 2012

Approved by

______, Nancy M. Docherty, PhD, Doctoral Dissertation Advisor

______, William Merriman, PhD, Doctoral Dissertation Committee

______, Janis Crowther, PhD, Doctoral Dissertation Committee

______, Steven Brown, PhD, Doctoral Dissertation Committee

______, Kristen Marcussen, PhD,Graduate Representative, Doctoral Dissertation Committee

Accepted by

______, Maria Zaragoza, Ph.D., Chair, Department of Psychology

______, Timothy Moerland, PhD., Dean, College of Arts and Sciences

Table of Contents.

List of tables………………………………………………………………………………………….…vi

Acknowledgements………………………………………………………………………………….….ix

Introduction………………………………………………………………………………………….….1

Literature review of empathy…………………………………………………………………..3

Empathic ability in schizophrenia……………………………………………………………...5

Alexithymia…………………………………………………………………………………….10

Alexithymia in schizophrenia…………………………………………………………………..11

The impact of alexithymia on the multifaceted aspects of empathy…………………………...14

The Present study……………………………………………………………………………....17

Hypotheses……………………………………………………………………………………………...18

Method………………………………………………………………………………………………….20

Table 1…………………………………………………………………………………………………..21

Results…………………………………………………………………………………………………..31

Table 2…………………………………………………………………………………………………..32

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Table 3…………………………………………………………………………………………………..35

Table 4…………………………………………………………………………………………………..38

Table 5…………………………………………………………………………………………………..40

Table 6…………………………………………………………………………………………………..42

Table 7…………………………………………………………………………………………………..42

Table 8…………………………………………………………………………………………………..43

Table 9…………………………………………………………………………………………………..43

Table 10…………………………………………………………………………………………………45

Table 11…………………………………………………………………………………………………46

Table 12…………………………………………………………………………………………………46

Table 13…………………………………………………………………………………………………47

Table 14…………………………………………………………………………………………………47

Table 15…………………………………………………………………………………………………51

Table 16…………………………………………………………………………………………………52

Table 17…………………………………………………………………………………………………53

Table 18…………………………………………………………………………………………………53

Table 19…………………………………………………………………………………………………54

Table 20…………………………………………………………………………………………………55

Table 21…………………………………………………………………………………………………57

Table 22…………………………………………………………………………………………………57

Table 23…………………………………………………………………………………………………58

Table 24…………………………………………………………………………………………………58

Discussion……………………………………………………………………………………………….60

Summary of Findings…………………………………………………………………………..60

Interpretation of Findings……………………………………………………………………....61

Planned Mediations…………………………………………………………………………….69

Exploratory Findings…………………………………………………………………………...69

Limitations…………………………………………………………………………………...... 76

Conclusions……………………………………………………………………………………………..78

References………………………………………………………………………………………..……..79

Appendix A. ……………………………………………………………………………………….…...93

List of Tables.

Table 1. Demographics, n= 120.

Table 2. Descriptive data.

Table 3. Correlations: Positive and Negative Syndrome Scale (PANSS) symptom variables, alexithymia, empathic ability, and social functioning.

Table 4. Correlations: PANSS symptom variables, alexithymia, empathic ability, social functioning, and clinician-rated negative emotionality.

Table 5. Correlations: PANSS symptom variables, alexithymia, empathic ability, social functioning, and neurocognitive measures.

Table 6. Mediation analysis: alexithymia mediating the relationship between PANSS total symptoms and

Social Functioning Scale (SFS) engagement subscale, n= 106.

Table 7. Mediation analysis: alexithymia mediating the relationship between PANSS positive symptoms and SFS engagement subscale, n= 113.

Table 8. Mediation analysis: alexithymia mediating the relationship between PANSS total symptoms and

SFS interpersonal subscale, n= 106.

Table 9. Mediation analysis: alexithymia mediating the relationship between PANSS positive symptoms and SFS interpersonal subscale, n= 113.

Table 10. Correlations: PANSS symptom variables, empathic ability, social functioning, and facets of the

Toronto Alexithymia Scale (TAS).

Table 11. Mediation analysis: TAS identifying emotions facet mediating the relationship between PANSS total symptoms and SFS engagement subscale, n= 106.

Table 12. Mediation analysis: TAS identifying emotions facet mediating the relationship between PANSS positive symptoms and SFS engagement subscale, n= 113.

Table 13. Mediation analysis: TAS identifying emotions facet mediating the relationship between PANSS total symptoms and SFS interpersonal subscale, n= 106.

Table 14. Mediation analysis: TAS identifying emotions on PANSS positive symptoms and SFS interpersonal subscale, n= 113.

Table 15. Factor analysis: PANSS symptom variables (positive, negative, and disorganized), alexithymia, and empathic ability.

Table 16. Mediation analysis: alexithymia mediating the relationship between PANSS total symptoms and clinician-rated negative emotionality, n= 108.

Table 17. Mediation analysis: alexithymia mediating the relationship between PANSS positive symptoms and clinician-rated negative emotionality, n= 116.

Table 18. Mediation analysis: clinician-rated negative emotionality mediating the relationship between

PANSS total symptoms and alexithymia, n= 108.

Table 19. Mediation analysis: clinician-rated negative emotionality mediating the relationship between

PANSS positive symptoms and alexithymia, n= 116.

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Table 20. Correlations: PANSS symptom variables, alexithymia, empathic ability, social functioning, and self-report negative emotionality.

Table 21. Mediation analysis: alexithymia mediating the relationship between PANSS total symptoms and the Beck Depression Inventory (BDI), n= 75.

Table 22. Mediation analysis: alexithymia mediating the relationship between PANSS positive symptoms and the BDI, n= 81.

Table 23. Mediation analysis: the BDI mediating the relationship between PANSS total symptoms and alexithymia, n= 75.

Table 24. Mediation analysis: the BDI mediating the relationship between PANSS positive symptoms and alexithymia, n= 81.

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Acknowledgements.

Thank you to Dr. Docherty, Amanda McCleery, Jim Seghers, Emily Bell-Schumann, Aubrey

Moe, Mohamed Shakeel, and Kristen Cimera for all the feedback, suggestions, and support throughout this project. I would also like to thank all those who support me: my family, friends, especially Mary, and

Joel.

Introduction.

Schizophrenia currently occurs in about one percent of the adult population worldwide, and is characterized by positive symptoms, as in hallucinations and delusions; negative symptoms, such as poverty of speech and flat affect; and disorganized symptoms, as in formal thought disorder and bizarre behavior. Deficits in social functioning—the ability to interact with others effectively and to contribute to society in general—also characterize schizophrenia. It has been well documented that people with schizophrenia have few social relationships (Buhrmester, 1990; Howard, Leese & Thronicroft, 2000;

Neumann & Walker, 1998) and limited social support (Caron, Tempier, Mercier, & Leouffre, 1998;

Milne, Wharton, James, & Turkington, 2006). Research has shown that social skills training can produce benefits to functional outcomes, e.g. employment and stable housing (Brekke, Kay, Lee, & Green, 2005), and quality of life improvements, e.g. a sense of well being and satisfaction with life (Eack, Newhill,

Anderson, & Rotondi, 2007; Ritsner, 2003). Although both the extent of social functioning deficits in schizophrenia and the benefits of social skills training are known, the reasons for the former are as yet unclear.

One possible source for deficient social functioning in schizophrenia is impaired empathy (Derntl et al., 2009; Lee, 2007). Empathy has been defined as a concept in psychology in a number of different ways, but is broadly understood as the ability to relate to others by discriminating among affective cues and assuming the perspective of another (Lee, Farrow, Spence, & Woodruff, 2004). Derntl et al. (2009) defined empathy as the multifaceted ability to recognize emotions through facial expression, speech and behavior; to understand emotional perspectives; and to respond to the needs of another effectively. For the purposes of this paper, a composite definition of empathy is most useful, empathy being the ability to recognize the emotions in a target person and to assume the perspective of the target (Lee et al., 2004). 1

Impairment in either of these skills might account for the social functioning deficits seen in people with schizophrenia (Derntl et al., 2009; Langdon & Ward, 2009).

The case has been made that knowledge of emotions in general and recognition of emotions in the self ultimately facilitate understanding, or taking the perspective, of others (Bagby et al., 1997).

Conversely, alexithymia, defined in this paper as the inability to identify, distinguish, and describe one‘s own emotions, has been theorized to hinder the development of empathy (Taylor & Bagby, 2000).

Alexithymia has been shown to be present in schizophrenia (Cedro, Kokoszka, Popiel & Narkiewicz-

Jodko, 2001; Serper & Berenbaum, 2008). The relationship between the severity of alexithymia and the lack of empathic ability should be considered, particularly in relationship to schizophrenia.

Gaining more knowledge about this relationship will allow for a more complete understanding of people with schizophrenia, and provide opportunities for improving treatments to yield meaningful social functioning gains. Yet there is a paucity of studies considering these variables in relation to each other.

The proposed study aims to extend knowledge in the field by assessing the relationships between alexithymia, empathy, and schizophrenia; particularly, the negative association of empathic ability with schizophrenic symptoms and social functioning, and the role of alexithymia in disrupting empathic ability. The introductory literature review examines the variables mentioned above and demonstrates their interrelatedness.

Literature Review of Empathy.

The Simulation Theory of empathy.

The neural basis of empathy is hypothesized to reside within a subset of neurons in the premotor and inferior parietal cortex known as the mirror neuron system (Gallese & Goldman, 1998). When a person performs a behavior, certain neurons fire in that person‘s brain; when the person observes another person performing the same behavior, mirror neurons fire in the observer‘s brain (Iacoboni, 2005;

Rizzolatti, 2005; Wild, Erb, Eyb, Bartels, & Grodd, 2003). Even if no behavioral output occurs when observing a target performing a behavior, the same firing is mirrored in the neurons as if the observer were performing the action. The Simulation Theory of empathy proposes that, much like neural simulation provoked by an observed action, empathy is also achieved via the mirror neuron system; mirror neurons fire in response to the facial expressions of another, representing that person‘s emotional states (Heal, 1996). During simulation, a person‘s brain imitates being in the target‘s situation, and the person draws upon past knowledge of his own emotional experiences in order to understand and empathize (Gallese & Goldman, 1998). For example, observing someone else furrow their brow in anger causes mirror neurons to fire similarly in the observer who thus mentally simulates the anger of the target

(Augustine, 1996; Carr, Iacoboni, Dubeau, Mazziotta, & Lenzi, 2003). Studies employing neuroimaging technology provide strong support for the Simulation Theory of empathy, because the firing of mirror neurons in response to both the behavior of the self and others has been directly observed (Adams, 2001).

Mirror neurons also seem to play a role in social functioning (Gallese, Keysers & Rizzolati, 2004;

Shamay-Tsoory, Shur, Harari & Levkovitz, 2007). For example, deficits in mirror neuron activity are common among children with autism, a pervasive developmental disorder marked by profound social functioning impairment (Dapretto et al., 2006; Pfeifer, Iaconobi, Mizziotta, & Dapretto, 2008). Mirror neuron deficits have also been linked to the social functioning impairments seen in schizophrenia (Arbib

& Mundhenk, 2005; Sanders, Gallup, Heinsen, Hof, & Schmitz, 2002). Deficits in empathy, including difficulties with emotion recognition and impairment in perspective-taking abilities, may result when a person does not have mirror neuron functioning adequate to simulate the emotions and experiences of another.

Another theory of empathy, the Theory-theory of empathy, advances the concept that humans have universal rules regarding social situations and interactions, and that these rules are applied when trying to empathize (Stich & Ravenscroft, 1994). Humans begin building ―theories‖ of social interaction during infancy and these theories are enhanced with each social interaction as new information is added to previous understanding (Vollm et al., 2006). While the Theory-theory and the Simulation Theory appear to advance conflicting ideas about how empathy develops, perhaps they are not truly in opposition.

Simulation Theory suggests that humans experience the emotions of another through neural mechanisms while the Theory-Theory says that people continuously aggregate information from the environment and past experiences to develop a more comprehensive interpretation of another person‘s state, such as intentions and beliefs (Adams, 2001). While both theories have been supported by research with various populations, and the two theories may coexist, the majority of research on people with empathic deficits has focused on the Simulation Theory and its neural basis for empathy. This paper will likewise focus on the Simulation Theory of empathy.

Empathic Ability in Schizophrenia.

Emotion recognition in schizophrenia..

All aspects of empathy, including emotion recognition and perspective-taking, are impaired to some extent in schizophrenia (Derntl et al., 2009; Lee, 2007). Emotion recognition, a focus of the proposed study, allows a person to glean emotional information from another‘s facial expression and tone of voice, as well as surrounding events (Mayer, DiPaolo, & Salovey, 1990; McFall, 1982; Toomey,

Seidman, Lyons, Faraone, & Tsuang, 1999). Facial emotion recognition is typically measured by asking participants to correctly identify the emotion of a target‘s facial expression in a still photograph.

Although individuals with schizophrenia have not evidenced facial emotion recognition deficits on the order of those observed in autism (Bolte & Poustka, 2003), the impairment has been significantly greater in schizophrenia than has been observed in other psychological disorders, including unipolar depression

(Archer, Hay & Young, 1992; Cutting, 1981; Gessler, Cutting, Frith & Weinman, 1989; Walker,

McGuire, & Betters, 1984), bipolar affective disorder (Addington and Addington, 1998), and anxiety disorders (Mandal & Rai, 1987). Impaired facial emotion recognition has also been seen in children and adolescents who later develop schizophrenia (Walker, Marwit & Emory, 1980). Although people with schizophrenia have tended to be more impaired than most other comparison groups, they generally have performed above chance level, indicating that facial emotion recognition abilities were not absent. Rather than being oblivious to facial expressions and their emotional significance, people with schizophrenia tended to mislabel some of the emotions being expressed, particularly demonstrating a bias toward attributing negative emotions to facial expressions, e.g. labeling a neutral expression as anger, and mistakenly identifying negative emotions, e.g. confusing anger with sadness (Baudouin & Franck, 2008).

Patients with schizophrenia have shown impairment for processing faces in general (Addington &

Addington, 1998; Kerr & Neale, 1993; Muesser et al., 1996; Salem, Kring & Kerr, 1996), and especially

for processing emotional information (Heimberg, Gur, Erwin, Shtasel & Gur, 1992; Penn et al., 2000).

These observed deficits may be related to abnormal facial scanning. Eye tracking studies suggest that individuals with schizophrenia may not scan the visual field sufficiently to gather facial emotion information about the target (Gordon et al., 1992; Phillips & David, 1998; Streit, Wolwer, & Gaebel,

1997). Most notably, people with schizophrenia spent less time during facial recognition tasks looking at emotionally-informative regions, such as the target‘s eyes, than non-psychiatric controls (Pelphrey et al.,

2002). The same tendency to avoid the target‘s eyes has been evidenced by people with autism

(Loughland, Williams & Gordon, 2002; Streit et al., 1997). One theory is that people with schizophrenia avoid looking at the eyes because of delusional thinking, such as fear of being stared at or having others read their minds (Lee, 2007).

In addition to facial expressions, tone of voice can provide information for emotion recognition.

Vocal emotion recognition studies, in which participants were asked to identify the correct emotion after listening to sentences of neutral content read with emotional inflection by male and female voices, showed recognition impairment in people with schizophrenia (Leitman et al., 2005). Deficient vocal emotion recognition has been associated with deficient facial emotion recognition (Kerr & Neale, 1993;

Leitman et al., 2005), linking poor use of such emotional information overall to schizophrenia. When

Cramer, Bowen and O‘Neill (1992) tested patients with schizophrenia on both empathy/social attention tasks and pure attention tasks, they found both were impaired but that patients‘ inattention was more severe for emotion-specific information.

Among schizophrenia patients, the degree of facial emotion recognition impairment appears to be associated with the severity of three kinds of symptoms: negative symptoms (Addington & Addington,

1998; Baudouin, Martin, Tiberghien, Verlut & Franck, 2002; Mandal, Jain, Haque-Nizamie, Weisse, &

Schneider, 1999), positive symptoms (Addington & Addington, 1998; Leitman et al., 2005; Silver,

Shlomo, Turner & Gur, 2002), and disorganized symptoms (Lee, 2007). Generally, greater severity of symptoms of schizophrenia is correlated with greater impairment in emotion recognition tasks.

Negative symptoms have been associated with cognitive deficits interfering with a person‘s ability to selectively attend to information, such as emotional information (Baudouin et al., 2002). Also, negative symptoms, characterized by social withdrawal and isolation, may result due to frustration and confusion regarding the social world brought on by poor empathic ability. Positive symptoms, clouding the distinction between reality and fantasy, can confuse the true intentions of others; for example, when a person believes a stranger wants to cause harm despite the absence of reality-based intention of harm

(Frith & Corcoran, 1996). Finally, disorganized symptoms may indicate underlying cognitive impairments that further impact the ability to organize and use social information, preventing a person from accurate and effective empathizing (Sarfati, Hardy-Bayle, Besche, & Widlocher, 1992). Although the causal direction of these relationships cannot be determined from the studies cited, clearly facial emotion recognition deficits are profoundly linked to schizophrenia symptoms.

Evidence further suggesting a significant relationship between empathy deficits and schizophrenia has been established in studies that found facial emotion recognition worsened during acute phases of the illness (Gessler et al., 1989; Penn et al., 2000; Wolwer, Streit, Polzer & Gaebel, 1996), although patients never fully remitted from this impairment (Wolwer et al., 1996). Other studies have found schizophrenia patients showed no improvement in facial emotion recognition, even outside of the acute phase of illness (Addington & Addington, 1998; Edwards, Pattison, Jackson & Wales, 2001; Streit et al., 1997). While psychotropic medications have not appeared to improve facial emotion recognition abilities (Gaebel & Wolwer, 1992; Lewis & Garver, 1995; Loughland et al., 2002), recent studies of behavioral interventions, training patients to focus attention on emotionally relevant information, were more promising (Kohler & Martin, 2006; Silver, Goodman, Knoll, & Isakov, 2004).

Perspective-taking in schizophrenia.

Another core component of empathy is perspective-taking, the ability to understand another person‘s internal state—essentially, ―to put oneself in another‘s shoes‖ (Ickes, 2009). Many studies use theory of mind (ToM) tasks, requiring participants to consider another‘s knowledge and mental state, as a means of measuring perspective-taking ability. Examples of ToM tasks include identifying interacting characters‘ motives from social stories (e.g., Social Script Stories; see Langdon & Coltheart, 1999), or asking participants to take the perspective of a cartoon character in order to explain why a joke is humorous (Joke Appreciation Task; Happe, Brownell, & Winner, 1999). Another ToM task presents still photographs in which one target portrays basic (i.e. happy, sad, and angry) or neutral facial emotions, while the other target‘s face is obscured from view. Participants must utilize information from the overall scene in the photograph, including body language and the visible person‘s emotional expression, to infer the emotion on the obscured person‘s face (ToM Picture Task; see Derntl et al., 2009).

Lee and colleagues (2004) conducted an extensive literature review of studies considering the relationship between schizophrenia and general social cognition, including perspective-taking ability. The authors concluded that people with schizophrenia demonstrated a reduced capacity to assume the perspective of another person (Derntl et al., 2009; Langdon & Ward, 2009), and this impairment was related to social functioning, resulting in such outcomes as withdrawal from others and poor occupational achievement. Moreover, there was evidence that perspective-taking deficits in schizophrenia extend beyond the effects of general cognitive impairment, suggesting that perspective-taking is separable from non-social cognitive ability (Langdon & Ward, 2009).

A more recent study found that people with schizophrenia were not able to appropriately take the perspective of a character in order to interpret ―faux pas‖ scenarios in which a character made a social gaffe and participants were asked to identify the social mistake that was made (Shur, Shamay-Tsoory, &

Levkovitz, 2008). People with schizophrenia performed poorly on this task consonant with the severity

of their symptoms (Shur et al., 2008). Interestingly, while these subjects were able to indicate that something was wrong in the faux pas scenarios, they could not identify what was specifically discordant.

Similar to the facial emotion recognition findings outlined above, this research revealed that people with schizophrenia may not have been entirely incapable of taking the perspective of another, but rather demonstrated diminished perspective-taking abilities relative to healthy controls.

Derntl and colleagues (2009) compared perspective-taking ability between people with schizophrenia and healthy controls using the ToM Pictures Task discussed earlier. They found that people with schizophrenia performed worse on this task than did healthy controls, even after statistically controlling for facial emotion recognition ability (Derntl et al., 2009). Their findings indicated that perspective-taking impairments could not simply be accounted for by emotion recognition deficits.

Langdon and Ward (2009) compared people with schizophrenia and healthy controls on both the ToM

Joke Appreciation and Social-Script Stories tasks; schizophrenia patients performed significantly worse on both tasks than did healthy controls. Further, poor performance on the ToM tasks was not accounted for by IQ or verbal memory impairments (Langdon & Ward, 2009), indicating that perspective-taking was a specific problem in their schizophrenia sample.

Social functioning impact of deficient empathy in schizophrenia.

Given that empathy involves understanding the emotional states and intentions of others, it is essential for effective social functioning. As a corollary, schizophrenia patients with poor empathic ability tend to demonstrate impaired social interactions and abilities. Penn, Spaulding, Reed and Sullivan

(1996) administered tasks of facial emotion recognition, self-reported concern for others, and perspective- taking to people with schizophrenia. They found their subjects were impaired on all empathy tasks, and that these impairments were better predictors of observed social behavior (e.g. reduced social interest and irritability) on an inpatient ward than were measures of general cognitive functioning, an outcome

suggesting the unique importance of empathic ability in social functioning above and beyond general cognitive ability. Within a Simulation Theory framework, one possible explanation for empathy impairments in people with schizophrenia is the influence of a separate construct, alexithymia. Severity of alexithymia might be related to impairment in a person‘s ability to identify and simulate the emotions of another, or to correctly label mirror-neurons simulations. The potential for this relationship is discussed below.

Alexithymia.

Alexithymia is defined in this paper as a condition characterized by difficulties in identifying a person‘s own emotions, distinguishing between physical sensations and emotional arousal, and describing a person‘s own emotions to other people (Bagby & Taylor, 1997). Alexithymia is typically assessed through self-report measures covering the aforementioned facets, with higher scores indicating greater severity of alexithymia; examples of self-report statements include ―I am often confused about what emotion I‘m feeling‖ and ―I am often puzzled by sensations in my body‖ (The 20-Item Toronto

Alexithymia Scale; TAS-20, Bagby, Taylor, & Parker, 1994). Following from Simulation Theory, accepting that a basic recognition and knowledge of emotions in the self is essential to recognizing emotions in others (Heal, 1996), and that the ability to recognize emotions and take the perspective of a target in turn is important for many kinds of social relationships (Crosby, 2002; Gleason, Jensen-

Campbell & Ickes, 2009), alexithymia might impair empathic ability, and ultimately inhibit a person from relating to others.

Alexithymia in Schizophrenia.

Alexithymia has been documented by a number of researchers to be present in people with schizophrenia (Cedro et al., 2001; Serper & Berenbaum, 2008; Stanghellini & Ricca, 1995). Li, Cheng,

Zhan and Li (2009) found that schizophrenia patients had greater self-reported severity of alexithymia than healthy controls, although severity was not greater than in manic or Major Depressive Disorder patients. Another study showed that people with schizophrenia had greater severity of alexithymia than people with major affective disorder, with the greatest severity for patients also suffering from Post- traumatic Stress Disorder (Spitzer, Vogel, Barrow, Freyburger, & Grab, 2007). In summary, the literature illustrates that presence and severity of alexithymia are common in people with schizophrenia.

Difficulty identifying emotions in schizophrenia.

Some studies have found that people with schizophrenia were often unable to identify their emotional states (Maggini & Raballo, 2004; Van der Meer, Van‘t Wout & Aleman, 2009). Van der Meer and colleagues (2009) found that people with schizophrenia self-reported having a more difficult time identifying their emotions than did healthy controls. Bodily sensations are often related to emotions

(Bagby & Taylor, 1997), e.g. a warm, flushed face being associated with embarrassment or anger.

Maggini and Raballo (2004) considered the association between self-reported severity of alexithymia and physical awareness, measured by the ability to connect physical sensations with a specific part or area of the body. In a schizophrenia sample, they found that a vague experience of sensations in the body, i.e. lacking knowledge of the specific location of these physical sensations, was related to somatic delusions and hallucinations (Maggini & Raballo, 2004). The authors reasoned that greater severity of alexithymia may promote delusional interpretations of physical sensations in schizophrenia.

Difficulty describing emotions in schizophrenia.

In addition to deficient awareness of their own emotions, people with schizophrenia tend to have difficulties expressing and verbally describing their emotions to others. Personal narratives, or autobiographies, are important for understanding others (Corcoran & Frith, 2003, 2005; Saxe, Moran,

Scholz, & Gabrieli, 2006) and studies have found that people with schizophrenia have had a difficult time generating personal narratives, particularly about their emotions and thoughts (Lysaker, Dimaggio, Buck,

Carcione & Nicolo, 2007). In one study, the barren quality of personal narratives, derived from psychiatric interviews with participants regarding the history and impact of their illness on their lives, was associated with a clinician-rated lack of knowledge and understanding of others (Lysaker et al., 2007).

According to Simulation Theory, lack of personal narratives could leave observers without a basis for comparison, putting them at a disadvantage for perspective-taking (Corcoran & Frith, 2003). Corcoran and Frith (2003) found that strong personal narratives of memories from childhood and adulthood were positively associated with the observer‘s ability to judge a perceived situation or the mental state of a target accurately. The authors also found that personal narratives were positively correlated with performance on a ToM task requiring participants to take the perspective and interpret the motives of a character by picking up on subtle social hints.

Alexithymia and symptoms in schizophrenia.

Severity of alexithymia has further been related to illness subtypes of schizophrenia, though not conclusively. Cedro et al. (2001) found that self-reported severity of alexithymia was most highly associated with paranoid schizophrenia, but also significantly associated with non-paranoid schizophrenia. In contrast, Stanghellini and Ricca (1995) found that severity of alexithymia was greater in non-paranoid, as compared to paranoid, schizophrenia. Within schizophrenia subtypes, severity of alexithymia is related to severity along symptom dimensions, e.g. positive and negative symptoms.

Serper and Berenbaum (2008) found that both schizophrenia and schizophrenia-spectrum patients reported difficulties identifying emotions on a self-report task, and that this impairment was related to severity of hallucinatory behavior (Serper & Berenbaum, 2008).

Severity of alexithymia has also been related to negative symptoms in schizophrenia such as flat affect and social withdrawal (Cedro et al., 2001; Nkam, Langlois-Thery, Dollfus, Petit, 1997; Stanghellini

& Ricca, 1995). However, not all studies have found such relationships (e.g. Todarello, Porcelli,

Grilletti, & Bellomo, 2005). Maggini and Raballo (2004) found that disorganized symptoms in schizophrenia, particularly disorganized speech, were related to difficulty identifying physical sensations which are often associated with emotions. Other studies have found a relationship between disorganized symptoms and alexithymia in people with schizotypal characteristics, considered to be on the non-clinical end of a schizophrenia-spectrum (Kerns, 2006; van‘t Wout, Aleman, Kessels, Laroi, & Kahn, 2004).

Without adequate knowledge of her emotions, a person may interpret feelings of sadness or anger as coming from an external source. Positive symptoms, like verbal hallucinations, often have negative content, such as hearing a voice saying that you are ―worthless,‖ or that ―you should die.‖ Perhaps the emotional content of the verbal hallucinations is associated with the true, although unidentified, feelings of the person experiencing the hallucinations, a displacement related to alexithymia; in other words, a person with negative feelings and low self-esteem may have the core belief that he is not worthy of living, but may not be aware of the belief and associated negative emotions, causing the belief to seem external.

Similarly, a lack of awareness of one‘s own emotions may feel isolating, resulting in social withdrawal or apathy, i.e. negative symptoms (Maggini & Raballo, 2004). Finally, disorganized symptoms, including disrupted thoughts and speech, may reflect the difficulty describing emotions associated with alexithymia.

Although there is some evidence for, and conceptual reasoning behind, associations of alexithymia with positive, negative and disorganized symptoms, research thus far is scant.

The Impact of Alexithymia on the Multifaceted Aspects of Empathy.

Research on healthy adults has shown severity of alexithymia to be related to aspects of poor empathic ability (Taylor & Bagby, 2000), such as emotion recognition difficulties (Lane et al., 1996;

Mann, Wise, Trinidad & Kohanski, 1994; Parker, Prkachin & Prkachin, 2005). Lane and colleagues

(1996) found that community members who self-reported high degrees of alexithymia demonstrated difficulties interpreting both verbal emotional stimuli, in which participants read a series of social vignettes and reported on a character‘s expected emotional response to an event, and nonverbal emotional stimuli, assessed through a facial emotion recognition task. In another study, high-alexithymia subjects were impaired in their ability to recognize emotions in photographs of faces (Mann et al., 1994). Parker and colleagues (2005) also found a partial relationship between self-reported severity of alexithymia and difficulty with facial emotion recognition. By contrast, adults who demonstrated a more refined understanding of their own emotional state, based on self-report, were found to be better able to identify the emotional state of a person viewed in a video (Petrides & Furnham, 2003). In short, recognition of a person‘s own emotions seems to contribute to recognition of others‘ emotions.

The relationship between severity of alexithymia and impaired empathic ability has also been seen in some clinical populations categorized as having disorders of social relating. Autistic children have shown greater severity of alexithymia than healthy children, and been less accurate on ToM tasks determining others‘ intentions and emotions (Baron-Cohen, 1995, 2003; Roeyers, Buysse, Ponnet &

Pichal, 2001). Men with antisocial personality disorder (APD) self-reported greater severity of alexithymia and demonstrated lower levels of empathic ability as determined by functional outcome measures related to family relationships (Sayar, Ebrinc & Ak, 2001). Also, maritally abusive men reported greater severity of alexithymia and showed more difficulty interpreting thoughts and emotions expressed by females about marital problems in videotaped therapy sessions, as compared to healthy controls (Clements, Holtzworth-Munroe, Schweinle & Ickes, 2007; Schweinle, Ickes, & Bernstein, 2002).

After re-viewing videotapes of conversations they had with their own wives, these men evidenced more difficulty than controls in empathizing with their wives (Clements et al., 2007).

When considering the impact of alexithymia on empathy in schizophrenia, some other variables should be considered. First, it is important to understand how affect influences both alexithymia and empathy impairment. Numerous studies have found significant associations between alexithymia and depression (Cedro et al., 2001; Honkalampi, Hintikka, Laukkanen, Lehtonen, & Viinamaki, 2001; Nkam et al., 1997) and anxiety (Cedro et al., 2001; Evren et al., 2008; Nkam et al., 1997). Studies have also found associations between empathy impairments and general distress, including both depression and anxiety (Fujiwara et al., 2008; Montag, Heinz, Kunz, & Gallinat, 2007; Shamay-Tsoory et al., 2007).

When feeling depressed, level of attention is often suppressed (Gualtieri, Johnson, & Benedict, 2006), which may lead to missing important social cues in the environment or difficulties identifying a person‘s own emotional state. Similarly, a person who is feeling anxious may avoid socially relevant information, such as looking at another‘s eyes, or be too concerned about his own actions to pay attention to those of other people. Thus, a person with alexithymia may feel a general amount of negative affect but have difficulty identifying his specific and unique emotional state, i.e. frustration, anger, apprehension, sadness, or dysphoria.

It is also important to consider the impact of neurcognitive abilities on alexithymia and empathic ability impairment in schizophrenia. Many neurocognitive abilities have been associated with empathy including premorbid and current intellectual ability (Brune, 2005; Pinkham & Penn, 2006), executive functioning (Derntl et al., 2009), and attention (Derntl et al., 2009; Pinkham & Penn, 2006; Toomey, et al., 1999). Low IQ has numerous origins, including prenatal and early developmental problems and head injury, and it is possible that damaged brain areas resulting in low IQ are also involved in empathic abilities. Lysaker et al. (2007) related alexithymia to executive functioning, reasoning that it is necessary for a person to manipulate information in order to understand the complexities of his own emotional

experiences. Executive functioning also includes the capacity to reason about others, which is important when engaging in ToM tasks. Additionally, the brain is extremely interconnected and the same areas used for executive functioning tasks are also used in processing facial features (Nomi et al., 2008). It has also been argued that poor attentional capacity is related to alexithymia because a person cannot adequately attend to her own emotional state (Serper & Berenbaum, 2008). Similarly, it is necessary for a person to attend to the world around him in order to gain social information necessary for empathizing.

Given the potential impact of neurocognition on empathy, these abilities will be considered as potential confounds in the relationships between severity of schizophrenic symptoms, alexithymia, and lack of empathic ability.

As demonstrated in this introduction, studies have shown that both severity of alexithymia and degree of empathic ability are separately related to schizophrenia. Despite the close relationship between severity of alexithymia and lack of empathic ability in other social-relating disorders, only one study (to the author‘s knowledge) has looked at the relationships among the three variables of interest: symptoms of schizophrenia, severity of alexithymia and empathic ability. Koelkebeck and colleagues (2010) compared first-episode schizophrenia patients with healthy controls on measures of empathy and alexithymia. Participants in this study completed a self-report questionnaire on alexithymia and two empathy measures: a self-report measure and a ToM measure in which participants provided social interpretations of two interacting triangles observed in silent videos. The authors found that people with schizophrenia who reported a difficult time identifying their emotions were more likely to use ToM- related words (e.g. ―admire‖ and ―trick‖) in order to describe the social interactions of the two triangles.

Correlations between alexithymia and empathy measures were found for both the schizophrenia and control groups, but schizophrenia patients performed significantly worse on the empathy tasks, and had significantly greater severity of alexithymia than controls (Koelkebeck et al., 2010).

Simulation Theory suggests that some people have a difficult time recognizing emotions and taking another‘s perspective because of deficits in simulating the mental and emotional state of others

(Langdon, Coltheart, & Ward, 2006). People with schizophrenia who show great severity of alexithymia may be hindered by problems in processing emotions from mirror neuron simulations of the emotions of others, and thus be less able to empathize. Not only is this an interesting theory for understanding patterns of deficits in schizophrenia, but it also has implications for treatment. Researchers and clinicians are becoming more interested in the effectiveness of empathy-based and social cognitive treatments for people with schizophrenia (Hogarty et al., 2004; Roberts, Penn, Labate, Margolis & Sterne, 2010; Silver et al., 2004). The present study aimed to contribute to our understanding of people with schizophrenia by looking at the relationship between severity of alexithymia and degree of empathic ability in schizophrenia. Studies of this relationship are lacking in the current literature.

The Present Study.

Based on the foregoing review of literature on schizophrenic symptoms, alexithymia, empathic ability, and social functioning, the present study aimed to test a number of hypotheses. First, the study aimed to examine the relationships among schizophrenic symptoms, severity of alexithymia, level of social functioning, and degree of empathic ability, as measured by emotion recognition and perspective- taking tasks. Second, it aimed to further clarify the nature of these relationships by considering how alexithymia is related to schizophrenic symptoms and impaired empathic ability. The purpose of elucidating these relationships is to inform treatment development for improving social skills and quality of life in people with schizophrenia. Finally, both negative emotionality and neurocognitive ability, which might affect empathic ability and severity of alexithymia, were included as control variables in an effort to determine whether the role of alexithymia in the relationship between schizophrenic symptoms and empathic ability remains distinct despite the influence of these potential third variables.

Hypotheses.

1. Schizophrenic symptoms will be related to severity of alexithymia, empathic ability, and social

functioning, such that as overall symptom severity increases, severity of alexithymia will

increase, indicating more difficulty identifying and describing a person‘s own emotions, and

empathic ability and social functioning will decrease, indicating more difficulty empathizing with

others and greater social dysfunction.

2. Certain clusters of symptoms will be independently related to severity of alexithymia and

empathic ability. In particular, more severe positive, negative and disorganized symptom

clusters, separately, will be related to greater severity of alexithymia, less empathic ability and

more social dysfunction, although some clusters may be more related to severity of alexithymia

than others.

3. Severity of alexithymia will partially mediate the relationship between symptom severity and

empathic ability, supporting the hypothesis that severity of alexithymia is one means by which

symptom severity has an effect on empathic ability.

A. Severity of alexithymia will partially mediate the relationship between total symptom

severity and empathic ability, supporting the hypothesis that severity of alexithymia is

one way in which symptoms of schizophrenia have an effect on empathic ability.

B. Severity of alexithymia will partially mediate the relationship between positive symptoms

and empathic ability, supporting the hypothesis that severity of alexithymia is one way in

which positive symptoms have an effect on empathic ability.

C. Severity of alexithymia will partially mediate the relationship between negative

symptoms and empathic ability, supporting the hypothesis that severity of alexithymia is

one way in which negative symptoms have an effect on empathic ability.

D. Severity of alexithymia will partially mediate the relationship between disorganized

symptoms and empathic ability, supporting the hypothesis that severity of alexithymia is

one way in which disorganized symptoms have an effect on empathic ability.

4. Negative emotionality may be related to severity of alexithymia and empathic ability, such that as

levels of clinician-rated depression and anxiety increase, severity of alexithymia might increase,

indicating less ability to identify and describe a person‘s own emotions, and empathic ability

might decrease, indicating less ability to empathize with others. Negative emotionality will be

assessed as a control variable in the hypothesized alexithymia-mediated relationships between

symptoms and empathic ability.

5. Neurocognitive ability may be related to symptom severity, severity of alexithymia and empathic

ability, such that as neurocognitive ability decreases, symptom severity and severity of

alexithymia might increase, and empathic ability might decrease. Neurocognitive ability will be

assessed as a control variable in the hypothesized alexithymia-mediated relationships between

symptoms and empathic ability.

6. Exploratory analyses will consider the relationships between: 1) the ―identifying emotions‖ facet

of alexithymia, schizophrenic symptom severity, empathic ability and social functioning; 2) the

―describing emotions‖ facet of alexithymia, schizophrenic symptom severity, empathic ability,

and social functioning; 3) self-reported negative emotionality, schizophrenic symptom severity,

severity of alexithymia, and empathic ability; and 4) how the variables of interest relate to each

other with alexithymia as the independent variable, empathic ability as the mediator, and

symptom severity as the dependant variable.

Method.

Participants.

Participants included 124 community members who were active clients at one of two community mental health centers in Akron, Ohio, and who met DSM-IV criteria for schizophrenia or schizoaffective disorder. Participants were recruited by means of signs posted in the clinics or by being recommended for the study by their case managers. Participants were excluded from the study if they had histories suggestive of organic complications (i.e. inhalant use, seizure disorder, head injury). Participants were mostly male (55%), African American (57%), and ranged in age from 18-50 with a median age of 42- years-old (Table 1).

Table 1: Demographics.

Male (%) 68 (54.8%)

Diagnosis

Schizophrenia (%) 60 (48.4%)

Schizoaffective Disorder 27 (21.8%) depressive subtype

Schizoaffective Disorder 37 (29.8%) bipolar subtype

Race

African American 71 (57.3%)

Caucasian 38 (30.6%)

Other 14 (11.3%)

Age median (range) 42 (18-50)

Education median (range) 12 (8-16)

Parent Education 12 (0-20)

Measures.

Diagnosis. A semi-structured diagnostic interview, the Schedule for Affective Disorders and

Schizophrenia—Lifetime Version (SADS—L; Spitzer & Endicott, 1978), adapted to be used with DSM-

IV criteria, was administered to each participant. Sections covering a number of psychological symptoms included current and life time histories of depressive and manic episodes, hallucinatory behavior and delusions, thought disorder, and substance use. Time lines were constructed to help differentiate between mood-driven psychotic symptoms and psychotic symptoms in the absence of mood disturbance. Chart review of participants‘ community mental health files were also used to corroborate diagnostic

information gleaned from the SADS. Diagnoses were determined by a clinical psychologist with extensive research diagnostic experience, based on information from the SADS interview and chart review.

Symptom Ratings. Symptom severities were rated with the Positive and Negative Syndrome Scale for Schizophrenia (PANSS; Kay, Flszbeln & Opler, 1987). All of the symptom ratings were done by graduate-level research assistants previously trained to good levels of inter-rater reliability on these scales. Co-ratings of audio-recorded interviews of 15 patients in the present study indicated good interrater reliability for PANSS ratings: total PANSS ICC=0.96, PANSS delusions ICC=0.95, PANSS hallucinations ICC=0.97, PANSS lack of spontaneous conversation ICC=0.93, and PANSS conceptual disorganization ICC=0.92. PANSS flat affect was also be used in this study; however there is not an ICC rating for this item because the rating requires actually seeing the participant, which was not possible with the co-raters. From these ratings, scores for overall symptomatology and positive, negative and disorganized symptoms were determined. Negative emotionality was determined from PANSS ratings and interrater reliabilities for these variables are PANSS depression ICC=0.95 and PANSS anxiety

ICC=0.99. Clinician-rated negative emotionality is used to avoid complications of self-reported depression and anxiety in participants who might have great severity of alexithymia, and thus be less able to identify their emotions. Although the clinician-ratings of negative emotionality are based in part on participant self-report, they are also based on behavioral signs, and therefore are considered better in this context than pure self-report measures. However, self-report measures of depression and anxiety also was considered in secondary, exploratory analyses to assess whether or not participants‘ self-reported negative emotionality was related to any of the other variables of interest. Two self-report negative emotionality measures, the BDI and STAI, are described below under mood measures.

Alexithymia. The 20-Item Toronto Alexithymia Scale (TAS-20; Bagby, Parker & Taylor, 1994;

Bagby et al., 1994) is a measure of alexithymia that consisted of three subscales: 1) ability to identify feelings and distinguish them from physical sensations, 2) the ability to describe one‘s feelings to others, and 3) externally-oriented thinking. The first two subscales are of most interest to the proposed study; therefore, externally-oriented thinking was not considered individually in this study. It is possible that externally-oriented thinking, as measured by the TAS-20, is not a stable facet of alexithymia and provides less clinically relevant information than the other two subscales (Honkalampi et al., 2001). For the purposes of the proposed study, the total TAS-20 score was used in the main analyses in order to assess participants‘ over-all severity of alexithymia, as has been done previously (Cedro et al., 2001). The first two subscales, ability to identify one‘s feelings and ability to describe one‘s feelings, were considered in secondary analyses to determine whether either of the subscales was more strongly related to the other variables of interest, such as empathic ability and social functioning. Items were rated from 1 (strongly disagree) to 5 (strongly agree) and possible scores ranged between 20 and 100, with higher scores indicating greater severity of alexithymia. Internal consistency of the TAS-20 is above 0.8, and goodness- of-fit for the three factor model is 0.98 (Parker, Taylor & Bagby, 2003). The measure shows good convergent validity with other measures of affect awareness, and adequate discriminant validity with a measure of openness to feelings (Babgy et al., 1994). Further, studies using this measure with schizophrenia patients have found the TAS-20 to relate to hallucinations and delusions (Serper &

Berenbaum, 2008) as well as negative symptoms (Cedro et al., 2001).

Empathic Ability. The Profile of Nonverbal Sensitivity Test (PONS; DePaulo, Rosenthal,

Finkelstein, & Eisenstat, 1979) is a 45-minute video that assesses nonverbal social perception and emotion recognition. The video consists of 220 two-second clips of nonverbal auditory and visual stimuli.

Each two-second clip involves either an audio bite, a video clip, or an audio bite with a video clip. All audio bites and video clips are of the same actress. The surroundings of the actress are not visible, forcing

the participant to rely on vocal cues and body language to determine the emotional content of the situation. The sound tracks for the auditory clips are muffled, so that comprehension of verbal content is not possible, requiring participants to use only the tone of voice, facial expressions, and movements of the actress to draw conclusions about her emotional state. After each two-second clip, the participants were asked to choose between two descriptions of everyday situations (e.g. (a) expressing jealous anger or (b) talking to a lost child). Half of the test was used for this study‘s purposes for a resulting 110 video/audio clips and questions. Two options were given for each item and one point was given for each correct response. Possible scores ranged from 0 to 110. For the purposes of this study, the PONS was used as a measure of emotion perception. The PONS was also combined with another measure to create a composite score of overall empathic ability, which is further discussed below. The PONS has been to shown to have good reliability (Toomey, Wallace, Corrigan, Schuldberg, & Green, 1997), and convergent validity of the PONS has been demonstrated with other measures of emotion perception and social cognition (Sergi et al., 2007). Comparison between schizophrenia and non-schizophrenia populations has demonstrated greater impairment in the schizophrenia group, F (2, 35)=12.45, p< 0.001, as would be expected (Monti & Fingeret, 1987).

The Assessment of Interpersonal Problem-Solving Skills (AIPSS; Donahoe et al., 1990) is a perspective- taking test of cognitive and behavioral skills. The task involves 13 videotaped vignettes, and one practice vignette, depicting social scenarios in which an interpersonal problem may or may not occur. Participants were asked to view each vignette, and take the perspective of one of the characters. After viewing the vignettes, participants were asked to indicate whether or not a problem occurred and, if the participant indicated affirmatively, to describe the problem from the point of view of their assigned characters.

Participants were given one point for correctly identifying whether or not there was an interpersonal problem in each vignette. Participants were then awarded scores between 0 and 2 for their description of the problem. Three vignettes were correctly identified as ―no problem,‖ resulting in possible scores

ranging from 0 to 33. The AIPSS has adequate test-retest reliability ranging from 0.46-0.77 and adequate discriminant validity has been demonstrated for the identifying and describing steps and IQ (Donahoe et al., 1990). Internal consistency ranges from 0.66-0.84 and the AIPSS has shown good convergent validity with other social perception measures (Corrigan & Toomey, 1995). The AIPSS has further been related to negative symptoms of schizophrenia and quality of life variables (Addington & Addington,

1999; Corrigan & Toomey, 1995), and performance on the AIPSS has been shown to improve after cognitive treatment for schizophrenia (Spaulding et al., 1999). For the purposes of this study, the AIPSS was used as a measure of perspective taking ability. Overall empathic ability was calculated as a composite score using standardized z-scores of the PONS and AIPSS measures in order to create a more complete assessment of empathic ability, including both recognition of emotion and perspective-taking.

Mood Measures. The Beck Depression Inventory-Second Edition (BDI-II; Beck, Steer & Brown,

1996) is a 21-item measure that assesses different aspects of depression, e.g. cognitive, affective, behavioral, motivational, and somatic state. Items were rated from 0 (not at all) to 3 (severely), and possible scores ranged between 0 and 63, with higher scores indicating greater severity of depression.

The measure has good internal consistency of above 0.9, and adequate convergent validity has been demonstrated with other measures of depression (Beck et al., 1996). The BDI has been used with patients with schizophrenia, and has shown adequate convergent validity with clinician-rated depression scales in this population (Addington, Addington & Maticka-Tyndale, 1993). Total BDI score was used in exploratory analyses of this study.

The State-Trait Anxiety Inventory Form Y (STAI; Spielberger, 1983) is composed of two 20-item self- report measures of temporary and trait-levels of anxiety. This instrument uses two scales which assess various aspects of anxiety including tension, apprehension, nervousness, and worry. This enables comparison of levels of anxiety during specific situations and the typical levels of anxiety on a day-to-day

basis. Items were rated from 1 (not at all) to 4 (very much so), and possible scores ranged between 0 and

80 for each measure, with higher scores indicating greater severity of anxiety. The measure has good internal consistency of above 0.9 (Ramaniah, Franzen & Schill, 1983), and good convergent validity has been demonstrated with other measures of anxiety (Nitschke, Heller, Imig, McDonald, & Miller, 2001;

Seedat, Fritelli, Oosthuizen, Emsley & Stein, 2007). The STAI has further been shown to be a good measure of anxiety in a schizophrenia population (Seedat et al., 2007). For the purposes of this study, only the state-anxiety score was used for exploratory analyses in order to consider the role of negative emotionality at the time of the assessment. The presence of anxiety symptoms may have potentially influenced participants‘ performances on other measures of interest.

Cognitive Tests. The Wisconsin Card Sort Test-64 Computer Version (WCST-64; Kongs,

Thompson, Iverson, & Heaton, 2000a) is a 10-15 minute computer-administered measure that assesses executive functioning. Executive functioning has been associated with performance on some empathy tasks in previous studies (Brune, 2005), and is therefore important to consider in the present analyses. The

WCST-64 presented participants with four stimulus cards (one red triangle, two green stars, three yellow crosses and four blue circles), and participants were asked to match 64 cards presented one at a time with one of the four stimulus cards. Matches were based on color, number or symbol, although the type of match required was unknown to the participant. When participants correctly matched 10 cards, the target match was changed and participants had to identify the new sorting rule. Convergent validity of the

WCST-64 with other measures of executive functioning ranges between 0.6-0.85 for adults (Kongs et al.,

2000b). For the purposes of this study, total number of errors was used in statistical analyses. Although other possible scores can be derived from the WCST-64, e.g. perseverative responses and numbers of categories achieved, the present study was less interested in specific types of errors and more interested in general executive functioning ability as it related to other measures. Executive functioning was considered a potential third variable in the main analyses.

The Shipley Institute of Living Scale (SILS; Shipley, 1940; Appendices G & H) is a proxy measure of general cognitive functioning. General cognitive functioning may have potentially impacted either empathic ability or social functioning, due to poor brain functioning overall, and was therefore considered in the present analyses. The measure consists of two subtests: one comprised of 40 multiple choice vocabulary words and the second comprised of 20 sequence questions involving letters and numbers. The vocabulary subtest measures verbal comprehension, acquired knowledge, long-term memory, and concept formation. The abstraction subtest assesses concept formation, abstract reasoning, cognitive flexibility, and sequencing ability. One point was given for each correct response on the vocabulary test, and two points for each correct item on the abstraction test. Possible scores for each subtest ranged between 0 and

40. Split-half reliability is 0.92 for the total score, and test-retest reliability has a median of 0.78 for the total score. The SILS has convergent validity ranging from 0.55-0.8 with other measures of cognitive ability. The SILS has been administered to a schizophrenia population and appears to be a valid measure of cognitive ability in this population (Deicken, Merrin, Floyd, & Weiner, 1995). A composite score derived from the vocabulary and abstraction subtests was considered in this study as a potential third variable in the main analyses.

The Trail Making Test A (TMT; Reitan & Wolfson, 1985) is a timed task in which participants are asked to connect a series of 25 numbered circles on a piece of paper in numerical order without lifting their pencil from the paper. Participants are timed to determine how quickly they complete the task correctly.

The Trail Making Test A is a measure of simple attention and processing speed, both of which may have potentially impacted empathic ability and social functioning, and was therefore considered in these analyses. This study used time-to-completion as a possible third variable in the main analyses. The

TMT-A has adequate test-retest reliability, although learning-based improvements have been demonstrated (Matarazzo, Wiens, Matarazzo, & Goldstein, 1974). The TMT-A has shown adequate

convergent validity with other neurocognitive measures. The TMT-A has been related to negative symptoms of schizophrenia (Vadhan, Serper, Harvey, Chou, & Cancro, 2001), and patients with schizophrenia have shown significantly worse performance on the TMT-A than controls, F=4.36, p<0.01

(Zalla et al., 2004).

Social functioning. The Social Functioning Scale (SFS; Birchwood, Smith, Cochrane, Wetton &

Copestake, 1990) is a clinician-administered interview assessing different areas of social functioning, including social engagement and withdrawal, interpersonal behavior, pro-social activities, recreation, competence for independent living, performance of independent living tasks, and employment or occupation. Scaled scores were calculated for each of the social functioning domains assessed, as well as for total score. For the purposes of the present study, the domain scores most relevant to social ability

(i.e. social engagement and interpersonal subscales) were used in statistical analyses. Full scale and subscale reliabilities range between 0.69-0.87, and the relationship between subscales and the full scale range from 0.63-0.8 (Birchwood et al., 1990). Also, patients with schizophrenia have shown significantly poorer social functioning on the SFS, as expected, compared with non-psychiatric matched controls,

F=95.6, p<0.001, and siblings, F=119.3, p<0.001 (Birchwood et al., 1990).

Procedure.

All participants were met with individually, and the measures, embedded in a larger protocol, were administered over four sessions separated by one week each, with the exception of the AIPSS which was administered in a fifth session after a six week interval following session four. Each session lasted approximately two hours; participants were paid $50 per session.

Statistical Analyses.

Two-tailed Pearson correlations were used to examine the associations between schizophrenia symptom severity, severity of alexithymia, empathic ability, and social functioning. Two-tailed Pearson correlations were looked at to examine the associations between specific types of schizophrenic symptom clusters, severity of alexithymia, and empathic ability.

It was hypothesized that the relationship between schizophrenia symptom severity and empathic ability would be mediated by alexithymia. Linear regression was used to assess the mediation effects of severity of alexithymia on the relationship between schizophrenia symptom severity and empathic ability.

Linear regression also was used to assess the mediation effects of severity of alexithymia on the relationships of specific clusters of schizophrenic symptoms, namely positive, negative and disorganized symptoms, and empathic ability. Separate linear regressions considering the mediation effects on the two aspects of empathic ability, emotion perception and perspective taking, were then conducted to gain more specific information about the relationships of the variables of interest. The bootstrapping technique, which does not require the assumption of normality and is beneficial when using small sample sizes, was calculated to assess significance (Preacher & Hayes, 2004). These regression equations tested for a partial mediation effect of severity of alexithymia on the relationship between schizophrenic symptoms and empathic ability, with the a priori expectation that entering alexithymia into the equation would reduce the correlation between schizophrenic symptoms and empathic ability. The present study was further interested in the effect of severity of alexithymia on the relationships between schizophrenic symptoms and empathic ability beyond the effects of negative emotionality and neurocognition. In these analyses, linear regression was used to assess the same mediation effects after entering negative emotionality and neurocognition as covariates.

Exploratory Analyses.

Linear regression was used to examine the impact of alexithymia on the relationships between symptom severities and social functioning. Two-tailed Pearson correlations were used in order to examine the associations between two subscales of alexithymia (identifying and describing emotions), schizophrenic symptom severity, empathic ability, and social functioning. Linear regression was used to examine the impact of the ―identifying emotions‖ facet of alexithymia on the relationships between symptom severities and social functioning. Strength of the alexithymia and empathic ability measures was assessed through item-to-scale correlations, comparing high versus low scorers, influence of abstraction ability, and factor analysis. Two-tailed Pearson correlations were also conducted in order to examine the association between clinician-rated and self-reported negative emotionality, schizophrenic symptoms, severity of alexithymia and empathic ability. Lastly, linear regression was used to examine the influence of negative emotionality on the relationships between symptom severities and alexithymia.

Results.

Descriptive Statistics.

All variables were normally distributed (skewness < 2 and kurtosis < 7). Means and standard deviations are displayed in Table 2. Six scores on the PONS were raised to the level of chance (from 22,

24, 50, 51, 52, and 54 to scores of 55 each). Subjects were excluded from some of the analyses for not having complete data due to missing individual measures or failing to return for follow-up sessions. All participants with available data were used in the relevant analyses resulting in different sample sizes for different analyses, as is noted in each analysis description.

PANSS variable data are presented in Table 2. The ranges of scores were comparable to those of other studies of stable outpatient populations (Brunelin et al., 2007; Docherty, St-Hilaire, Aakre, &

Seghers, 2009). A composite score was computed by adding PANSS anxiety and PANSS depression items to create a single measure of clinician-rated negative emotionality.

Alexithymia, empathy, and social functioning data are presented in Table 2. Total scores on the

TAS were similar to those reported by Cedro et al. of an outpatient population (2001) and had a

Chronbach‘s alpha of 0.808. Scores on the PONS were similar but higher, as would be expected, than scores reported of a chronic inpatient population (Toomey, Schuldberg, Corrigan, & Green, 2002) with a

Chronbach‘s alpha of 0.780, and scores on the AIPSS were similar to those reported of a stable outpatient population by Addington and Addington (1999) with a Chronbach‘s alpha of 0.885. For purposes of analyses, a composite score was computed using standardized z-scores from the PONS and the AIPSS to create a single measure of empathic ability. Scores on the SFS were similar to those reported of an outpatient population by Addington and Addington (1999).

Table 2: Descriptive Data.

N Mean SD Range PANSS Total 111 66.73 16.98 34-113 PANSS positive symptoms 119 6.34 2.77 2-12 PANSS negative symptoms 120 3.77 1.90 2-10 PANSS disorganized symptoms 121 2.25 1.19 1-6 PANSS depression 121 2.99 1.52 1-7 PANSS anxiety 121 3.18 1.43 1-7 Negative Emotion 121 6.17 2.60 2-14 TAS Total 122 56.44 13.13 24-83 TAS Identify Emotions 122 20.36 7.60 7-35 TAS Describing Emotions 122 15.26 4.63 5-25 PONS Total Correct 118 73.37 9.56 55-91 AIPSS Percent Correct 82 66.34 15.21 33-100 Empathic Ability 78 -0.12 1.44 -3.81-3.27 SFS Social Engagement Scale 121 99.93 12.28 75.5-133 SFS Interpersonal Scale 121 118.94 17.08 78-145 SILS Total 122 38.92 13.81 14-69 WCST Total Errors 112 29.54 12.45 7-53 TMT A time to completion 123 20.50 9.72 7-54 Neurocognitive Ability 109 -0.05 2.08 -4.12-5.35 BDI 88 19.90 12.30 0-54 STAI 87 46.55 6.36 31-64 Self-report Negative Emotion 83 -0.03 1.33 -3.35-3.47 PANSS = Positive and Negative Syndrome Scale for Schizophrenia; Negative Emotion = (PANSS depression + PANSS anxiety); TAS = 20-Item Toronto Alexithymia Scale; PONS = Profile of Nonverbal Sensitivity Task; AIPSS = Assessment of Interpersonal Problem-Solving Skills; Empathic Ability = (standardized z-scores of PONS + AIPSS ); SILS = Shipley Institute of Living Scale; WCST = Wisconsin Card Sort Test; TMT A = Trail Making Task A; Neurocognitive Ability = (standardized z-scores of SILS + WCST + TMT A); BDI = Beck Depression Inventory; STAI = State-Trait Anxiety Inventory; Self- report Negative Emotion = (standardized z-scores of BDI + STAI)

Neurocognitive and affective data are presented in Table 2. A composite score was computed using standardized z-scores from the TMT, WCST, and reverse-scored SILS to create a single measure of neurocognitive ability. Time-to-completion on the TMT A was faster than other studies using outpatient populations (Bellack, Gold, & Buchanan, 1999; Rempfer, Hamara, Brown, & Bothwell, 2006). Scores on the WCST were similar to scores reported on outpatient schizophrenia populations (Lee et al., 2006;

Purdon, Malla, Labelle, & Lit, 2001). Scores on the SILS were similar to those reported on an outpatient schizophrenia population (Seghers & Docherty, 2009). A composite score was computed using

standardized z-scores from the BDI and STAI to create a single measure of self-reported negative emotionality. Scores on the BDI were higher than an outpatient group of mostly schizophrenia and a few schizoaffective patients (Chronbach‘s alpha= 0.924), but STAI scores were similar (Bayard, Capdevielle,

Boulenger, & Raffard, 2009) with a Chronbach‘s alpha of 0.944; it is possible the inclusion of schizoaffective disorder participants accounted for some of the differences.

Demographic variables were considered potential third variables affecting the associations of interest. Group differences for diagnosis (i.e. schizophrenia versus schizoaffective disorder) were found on the PONS (F (1, 116) = 5.455, p < 0.05) and neurocognitive ability (F (1, 107) = 4.597, p = 0.05). The schizophrenia group performed more poorly on the PONS and neurcognitive ability tasks than the schizoaffective group. Given the significant group differences, analyses including the PONS and/or neurocognitive ability were conducted by diagnostic group, as well as for the entire sample. Group differences for gender were found on neurocognitive ability (F (1, 106) = 4.968, p < 0.05); female participants performed more poorly on neurocognitive tasks than male participants. Analyses including neurocognitive ability were conducted for males and females separately in addition to being conducted for the entire sample. Group differences for educational level were found on neurocognitive ability (F (2,

104) = 8.533, p < 0.01); participants who completed the 12th grade performed better than those who did not, and performed more poorly than those with more than a 12th grade education. Analyses including neurocognitive ability were conducted for educational group (i.e. less than 12 years, 12 years, and more than 12 years) separately in addition to being conducted for the entire sample. There were no significant group differences based on age, race, or parent‘s education (a proxy measure of socioeconomic status).

Tests of Hypotheses.

Associations of Symptoms, Alexithymia, Empathy and Social Functioning.

1. Schizophrenic symptoms will be related to severity of alexithymia, empathic ability, and social

functioning, such that as overall symptom severity increases, severity of alexithymia will

increase, indicating more difficulty identifying and describing one‘s own emotions, and empathic

ability and social functioning will decrease, indicating more difficulty empathizing with others

and greater social dysfunction.

To test this hypothesis, Pearson correlations were conducted looking at the relationships between total symptom severity, alexithymia, empathic ability and social functioning. Most relationships were in the expected direction, although few significant relationships emerged. Symptom severity was related to the TAS (r = 0.166; Table 3) and the PONS (r = -0.165; Table 3), but only as trend relationships.

Symptom severity was not related to the AIPSS or overall empathic ability. The TAS and PONS were related at a trend level (r = 0.174; Table 3), but in the opposite direction from that expected; the TAS was not related to the AIPSS or empathic ability. The social functioning engagement scale was significantly related to symptom severity (r = -0.230; Table 3), and had a trend relationship with alexithymia in the expected direction (r = -0.157, respectively; Table 3). The social functioning interpersonal scale was significantly related to symptom severity and alexithymia (r = -0.273 and r = -0.200, respectively; Table

3). No other significant relationships were found between either of the social functioning scales, PONS,

AIPSS, or empathic ability (Table 3). The PONS and AIPSS were not significantly related to one another

(r = -0.032; Table 3), possibly due to the measures assessing different aspects of empathy, namely emotion perception and perspective taking ability. Therefore, analyses were run using the composite score, empathic ability, and the PONS and AIPSS separately to consider the effects on individual facets of empathy.

Table 3: Correlations between PANSS symptom variables, alexithymia, empathic ability, and social functioning.

1. 2. 3. 4. 5. 6. 7. 8. 9.

1. PANSS Total

2. 0.663** PANSS Positive

3. 0.413** -0.078 PANSS Negative

4. 0.348** 0.264** 0.023 PANSS Disorgan -ized

5. TAS 0.166† 0.207* -0.097 -0.023 Total

6. PONS -0.165† -0.083 -0.179† -0.284** 0.174†

7.AIPSS 0.133 0.121 0.040 0.026 0.148 -0.032

8. -0.014 0.090 -0.164 -0.206† 0.174 0.706** 0.685** Empathic Ability

9. SFS -0.230* -0.192* -0.097 -0.098 -0.157† -0.084 -0.079 -0.087 Engage- ment

SFS -0.273** -0.275** -0.175† 0.139 -0.200* -0.138 0.106 -0.097 0.338** Interper- sonal

**p< 0.01, *p< 0.05, †p< 0.1 PANSS = Positive and Negative Syndrome Scale for Schizophrenia; TAS = 20-Item Toronto Alexithymia Scale; PONS = Profile of Nonverbal Sensitivity Task; AIPSS = Assessment for Interpersonal Problem- Solving Skills; Empathic Ability = (standardized z-scores of PONS + AIPSS); SFS = Social Functioning Scale

2. Certain clusters of symptoms will be independently related to severity of alexithymia and

empathic ability. In particular, more severe positive symptom, negative symptom and

disorganization symptom clusters, separately, will be related to greater severity of alexithymia,

less empathic ability and more social dysfunction; although some clusters may be more related to

severity of alexithymia than others.

To test this hypothesis, Pearson correlations were conducted looking at the relationships between positive, negative and disorganized clusters of symptoms, alexithymia, empathic ability and social functioning. Although most of the relationships were in the expected direction, few significant relationships emerged. Positive symptoms were significantly related to alexithymia, the social functioning engagement and interpersonal scales (r= 0.207, r = -0.192 and r = -0.275, respectively; Table

3). No other significant relationships were found with positive symptoms. Two trend relationships were found for negative symptoms with the PONS and the social functioning interpersonal scale (r = -0.179 and r = -0.175, respectively; Table 3). A significant relationship was found between disorganized symptoms and the PONS (r= -0.284; Table 3), and a trend relationship was found between disorganized symptoms and empathic ability (r = -0.206; Table 3). No significant relationships were found between disorganized symptoms and alexithymia, the AIPSS, empathic ability, or social functioning.

Mediation Analyses.

3. Severity of alexithymia will partially mediate the relationship between symptom severity and

empathic ability, supporting the hypothesis that severity of alexithymia is one means by which

symptom severity has an effect on empathic ability.

Because of the lack of strong associations among the variables of interest, mediation was unlikely. Planned mediations were conducted, the results of which can be found in Appendix A. Results of all mediational models were found to be non-significant, even after controlling for diagnosis on those predicting the PONS as a dependant variable.

Effects of Negative Emotion.

4. Negative emotionality may be related to severity of alexithymia and empathic ability, such that as

levels of clinician-rated depression and anxiety increase, severity of alexithymia might increase,

indicating less ability to identify and describe one‘s own emotions, and empathic ability might

decrease, indicating less ability to empathize with others. Negative emotionality will be assessed

as a control variable in the hypothesized alexithymia-mediated relationships between symptoms

and empathic ability.

To test this hypothesis, Pearson correlations were conducted looking at the relationships of

PANSS anxiety, PANSS depression, and clinician-rated negative emotionality (a composite score computed from PANSS anxiety and PANSS depression scores) to symptom severity, alexithymia, empathic ability and social functioning. For these analyses, overall symptom severity was computed as the PANSS total score minus the anxiety and depression items to prevent erroneous correlations. All negative emotionality variables were associated with overall symptom severity, and positive and negative symptoms, but not disorganized symptoms (Table 4). Alexithymia was significantly related to PANSS anxiety, PANSS depression and clinician-rated negative emotionality (r= 0.208, r=0.268 and r = 0.271, respectively; Table 4). No significant relationships were found for any of the negative emotionality variables with the PONS, AIPSS or overall empathic ability (Table 4). The social functioning

engagement and interpersonal scales were significantly related to all negative emotionality variables

(Table 4).

Table 4: Correlations between variables of interest and clinician-rated negative emotionality.

PANSS Anxiety PANSS Depression Negative Emotion

PANSS Total 0.498** 0.511** 0.672**

PANSS Positive 0.380** 0.395** 0.441**

PANSS Negative 0.151† 0.176† 0.186*

PANSS Disorganized 0.032 -0.073 -0.025

TAS Total 0.208* 0.268** 0.271**

PONS 0.081 0.104 0.106

AIPSS 0.026 0.041 0.038

Empathic Ability 0.158 0.109 0.150

SFS Engagement -0.219* -0.208* -0.242**

SFS Interpersonal -0.325** -0.380** -0.400**

PANSS Depression 0.547**

Negative Emotion 0.872** 0.890**

**p< 0.01, *p< 0.05, †p< 0.1 PANSS = Positive and Negative Syndrome Scale for Schizophrenia; Negative Emotion = (PANSS anxiety + PANSS depression); TAS = 20-Item Toronto Alexithymia Scale; PONS = Profile of Nonverbal Sensitivity Task; AIPSS = Assessment of Interpersonal Problem-Solving Skills; Empathic Ability = (standardized z-scores of PONS + AIPSS); SFS = Social Functioning Scale

Given the significant relationships between clinician-rated negative emotionality and alexithymia, mediations considering clinician-rated negative emotionality as a covariate were conducted using linear regression. None of the mediational models were improved with the addition of negative emotionality;

these results were perhaps due to the lack of relationship between clinician-rated negative emotionality and empathy, or the lack of significant mediations prior to the influence of covariates.

Effects of Neurocognitive Ability.

5. Neurocognitive ability may be related to symptom severity, severity of alexithymia and empathic

ability, such that as neurocognitive ability decreases, symptom severity and severity of

alexithymia might increase, and empathic ability might decrease. Neurocognitive ability will be

assessed as a control variable in the hypothesized alexithymia-mediated relationships between

symptoms and empathic ability.

To test this hypothesis, Pearson correlations were conducted looking at the relationships of the

SILS, WCST, TMT A, and overall neurocognitive ability (a composite score using the SILS, WCST, and

TMT A) to symptom severity, alexithymia, and empathic ability (Table 5). Although most of the relationships were in the expected direction, few significant relationships emerged. Trend relationships were found between 1) positive symptoms and the SILS, 2) negative symptoms and TMT A, and 3) disorganized symptoms and the WCST (Table 5). Neurocognitive ability had a trend relationship with disorganized symptoms (Table 5), but not with any of the other symptom variables. The PONS was significantly related to the SILS, WCST, and neurocognitive ability (Table 5). The AIPSS was significantly related to the WCST, and trend relationships were found between the AIPSS, the SILS and neurocognitive ability (Table 5). Empathic ability had trend relationships with the SILS and neurocognitive ability (Table 5). No significant relationships were found between neurocognitive variables and alexithymia or social functioning, although there was a trend relationship between TMT A and the social functioning engagement (Table 5).

Table 5: Correlations between variables of interest and neurocognitive measures.

SILS WCST TMT A Neurocognition

PANSS Total -0.079 0.161 0.020 0.091

PANSS Positive -0.176† 0.118 -0.128 0.078

PANSS Negative 0.082 0.111 0.204* 0.061

PANSS Disorg. -0.127 0.182† 0.171 0.187†

TAS -0.026 0.074 -0.122 -0.040

PONS 0.399** -0.332** -0.021 -0.395**

AIPSS -0.194† -0.249* 0.061 0.223†

Empathic Ability 0.200† -0.106 -0.111 -0.201†

SFS engagement -0.018 -0.030 0.177† 0.087

SFS interpersonal -0.026 0.007 0.084 0.030

WCST -0.361**

TMT A -0.080 0.174†

Neurocognition -0.725** 0.740** 0.618**

**p< 0.01, *p< 0.05, †p< 0.1 PANSS = Positive and Negative Syndrome Scale for Schizophrenia; TAS = 20-Item Toronto Alexithymia Scale; PONS = Profile of Nonverbal Sensitivity Task; AIPSS = Assessment of Interpersonal Problem- Solving Scale; SFS = Social Functioning Scale; SILS = Shipley Institute of Living Scale; WCST = Wisconsin Card Sort Task; TMT A = Trail Making Task A

Given the significant relationships between neurocognitive variables, the PONS and the AIPSS, mediations considering neurocognitive ability as a covariate were conducted using linear regression.

None of the mediational models were improved with the addition of neurocognitive ability; these findings were perhaps due to the lack of relationship between neurocognitive ability and alexithymia, or the lack of significant mediations prior to the influence of covariates. Further, none of the mediational models were improved when considering men and women separately, diagnostic groups separately, or educational level.

Exploratory Analysis.

None of our planned hypotheses were supported. A number of exploratory analyses were conducted in order to better understand the relationships, and lack thereof, between symptom severity, alexithymia, empathic ability, and social functioning.

Influence of Alexithymia on the Relationship Between Symptoms and Social Functioning.

Given the significant correlations of social functioning with overall symptom severity, positive symptoms and alexithymia, linear regression was conducted to consider alexithymia as a mediator in the relationship between symptoms and social functioning. Despite significant correlations, alexithymia did not significantly mediate relationships between symptoms and social functioning (Tables 6-9).

Table 6: Regression—PANSS total symptoms (IV), TAS (M), and SFS engagement (DV).

B SE B Beta t (p- R² (adj F (2, 104) value) R²)

IV on DV -0.150 0.067 -0.212 -2.223 (0.028)

IV on M 0.125 0.072 0.166 1.737 (0.085)

M on DV -0.112 0.089 -0.121 -1.261 (0.210)

IV on DV (w -0.137 0.068 -0.193 -2.008 0.059 3.279 M) (0.047) (0.041) (0.042)

Boot CI -0.0500 and 0.0103

Table 7: Regression—PANSS positive symptoms (IV), TAS (M), and SFS engagement (DV).

B SE B Beta t (p-value) R² (adj F (2,111) R²)

IV on DV -0.739 0.410 -0.168 -1.800 (0.075)

IV on M 0.945 0.461 0.207 2.269 (0.025)

M on DV -0.109 0.090 -0.115 -1.215 (0.227)

IV on DV (w -0.639 0.418 -0.145 -1.531 0.041 2.365 M) (0.129) (0.024) (0.099)

Boot CI -0.3488 and 0.0840

Table 8: Regression—PANSS total symptoms (IV), TAS (M), and SFS interpersonal (DV).

B SE B Beta t (p-value) R² (adj F (2, 104) R²)

IV on DV -0.268 0.094 -0.267 -2.835 (0.006)

IV on M 0.125 0.072 0.166 -1.737 (0.085)

M on DV -0.200 0.124 -0.152 -1.614 (0.110)

IV on DV (w -0.244 0.095 -0.243 -2.574 0.094 5.381 M) (0.011) (0.076) (0.006)

Boot CI -0.0834 and 0.0104

Table 9: Regression—PANSS positive symptoms (IV), TAS (M), and SFS interpersonal (DV).

B SE B Beta t (p-value) R² (adj F (2, 111) R²)

IV on DV -1.624 0.558 -0.265 -2.912 (0.004)

IV on M 0.945 0.416 0.207 2.269 (0.025)

M on DV -0.169 0.122 -0.128 -1.384 (0.169)

IV on DV (w -1.471 0.566 -0.240 -2.597 0.086 5.234 M) (0.011) (0.070) (0.007)

Boot CI -0.5566 and 0.0606

Associations of Symptoms, Empathy, and Social Functioning with Facets of Alexithymia.

As mentioned in the introduction, relationships of different facets of alexithymia with other variables of interest are important to consider. In these exploratory analyses, two-tailed Pearson correlations were conducted looking at the relationships between the ―identifying emotions‖ facet of alexithymia, symptom severity and social functioning. Few significant relationships emerged.

Identifying emotions was significantly related to positive symptoms, PONS, empathic ability, and the

SFS interpersonal subscale (Table 10). Identifying emotions was related at a trend level to overall symptom severity and the social functioning engagement scale (Table 10). Linear regressions were conducted looking at ―identifying emotions‖ as a mediator in the relationships between 1) overall symptom severity and the SFS engagement subscale, 2) positive symptoms and the SFS engagement subscale, 3) overall symptom severity and the SFS interpersonal subscale, and 4) positive symptoms and the SFS interpersonal subscale; significant mediations were not found for any of the models (Tables 11-

14).

Table 10: Correlations between PANSS symptom variables, empathic ability, social functioning, and components of the TAS.

TAS Identify TAS Describe Emotions Emotions

PANSS Total 0.166† 0.053

PANSS Positive 0.236* 0.088

PANSS Negative -0.118 -0.154

PANSS Disorganized 0.014 -0.013

PONS 0.196* 0.192*

AIPSS 0.181 0.050

Empathic Ability 0.243* 0.084

SFS Engagement -0.159† -0.160†

SFS Interpersonal -0.182* -0.112

TAS Describe Emotions 0.745**

TAS ID and DESC combined 0.963** 0.897**

**p< 0.01, *p< 0.05, †p< 0.1 PANSS = Positive and Negative Syndrome Scale for Schizophrenia; TAS = 20-Item Toronto Alexithymia Scale; PONS = Profile of Nonverbal Sensitivity Scale; AIPSS = Assessment of Interpersonal Problem- Solving Skills; SFS = Social Functioning Scale

Table 11. Regression—PANSS total symptom severity (IV), TAS identifying emotions (M), and SFS engagement (DV).

B SE B Beta t (p-value) R² (Adj F (2, 104) R²)

IV on DV -0.150 0.067 -0.212 -2.223 (0.028)

IV on M 0.073 0.042 0.166 1.741 (0.085)

M on DV -0.151 0.153 -0.096 -0.989 (0.325)

IV on DV -0.139 0.068 -0.197 -2.036 0.054 2.956 (w/ M) (0.044) (0.036) (0.065)

Boot CI -0.0473 and 0.0133

Table 12: Regression—PANSS positive symptoms (IV), TAS identifying emotions (M), and SFS engagement (DV).

B SE B Beta t (p-value) R² (Adj F (2, 111) R²)

IV on DV -0.739 0.410 -0.168 -1.800 (0.075)

IV on M 0.633 0.243 0.236 2.604 (0.010)

M on DV -0.192 0.154 -0.119 -1.245 (0.216)

IV on DV -0.619 0.421 -0.140 -1.471 0.042 2.403 (w/ M) (0.144) (0.024) (0.095)

Boot CI -0.4114 and 0.0838

Table 13: Regression—PANSS total symptom severity (IV), TAS identifying emotions (M), and SFS interpersonal (DV).

B SE B Beta t (p-value) R² (Adj F (2, 104) R²)

IV on DV -0.268 0.094 -0.267 -2.835 (0.006)

IV on M 0.073 0.042 0.166 1.741 (0.085)

M on DV -0.284 0.213 -0.126 -1.331 (0.186)

IV on DV -0.247 0.095 -0.246 -2.596 0.087 4.934 (w/ M) (0.011) (0.069) (0.009)

Boot CI -0.0782 and 0.0143

Table 14: Regression—PANSS positive symptoms (IV), TAS identifying emotions (M), and SFS interpersonal (DV).

B SE B Beta t (p-value) R² (Adj F (2, 111) R²)

IV on DV -1.624 0.558 -0.265 -2.912 (0.004)

IV on M 0.633 0.243 0.236 2.604 (0.010)

M on DV -0.241 0.209 -0.108 -1.150 (0.252)

IV on DV -1.473 0.572 -0.241 -2.575 0.081 4.915 (w/ M) (0.011) (0.065) (0.009)

Boot CI -0.6022 and 0.1114

Pearson correlations were conducted looking at the relationships between the ―describing emotions‖ facet of alexithymia, symptom severity, empathic ability and social functioning. A significant relationship was found between describing emotions and the PONS, and a trend relationship was found between describing emotions and the SFS engagement subscale (Table 10). No other significant correlations were found between describing emotions, symptom variables, the AIPSS, empathic ability, or the SFS interpersonal subscale. Possible mediations with the ―describing emotions‖ facet of alexithymia were not implicated and were not conducted.

Assessing the Strength of the TAS-20 as a Measure in the Current Study.

It is also possible that the lack of relationship between alexithymia and empathic ability was due to problems with the TAS. Item-to-scale correlations were conducted, with individual items having correlations with the scale between -0.029 and 0.713; the TAS showed an alpha of 0.808 when all 20 items were included. Eight of the items on the TAS had a correlation coefficient below 0.3, and were therefore removed to improve the reliability of the scale. A recalculated TAS scale with 12 items— including all the items from the ―identifying emotions‖ subscale, four items from the ―describing emotions‖ subscale, and one item from the ―externally oriented thinking‖ subscale—had an alpha of

0.882. The 12-item TAS was significantly correlated to a greater extent with the same variables as the full 20-item TAS (Table 3), and a previous trend relationship became a significant correlation between the

12-item TAS and social functioning engagement scale.

Analyses Comparing High and Low Scoring Groups for Alexithymia and Empathy.

We considered that non-significant findings may have been the result of looking at variables continuously. The TAS was split into a ―low scoring‖ group (1 standard deviation or more below the mean) and a ―high scoring‖ group (1 standard deviation or more above the mean). A one-way ANOVA was conducted to determine whether there were group differences on the PONS between high and low scorers on the TAS, but no significant group differences were found (F (1, 41) = 1.899, p = 0.176). The

PONS was also split into ―low scoring‖ and ―high scoring‖ groups, using the same 1-standard-deviation criterion, and a one-way ANOVA was conducted to determine whether there were group differences on the TAS between low and high scorers on the PONS; no significant group differences were found (F (1,

35) = 1.044, p = 0.314).

Influence of Level of Abstraction on the Relationships between Alexithymia, Symptoms, Empathic

Ability, and Social Functioning.

We considered that performance on the TAS might have been influenced by a person‘s capacity for abstract thinking. Thinking about one‘s own ability to identify and describe his emotions is a higher- order process and requires a degree of insight into the self. Therefore, we compared participants who performed well on the abstraction subtest of the SILS (i.e. half a standard deviation or more above the mean) with those who performed poorly on the abstraction subtest (i.e. half a standard deviation or less below the mean). Those who performed above the mean on the SILS abstraction subtest (scores greater than 20) had a significant relationship between the TAS and the PONS (r = 0.356), indicating that in participants with greater abstract thinking abilities, better performance on the emotion perception task was associated with greater alexithymia, i.e. a more difficult time identifying and describing their own emotions. Those who performed below the mean on the SILS abstraction test (scores less than 11) did

not have a significant relationship between the TAS and the PONS (r = 0.133), indicating that in participants with poor abstract thinking abilities, difficulties in identifying and describing their own emotions were not related to performance on the emotion perception task.

Analyses Considering the Empathy Measures Utilized.

We considered that empathy, alexithymia, and symptom variables were perhaps not related because they were associated with different underlying factors, and therefore would not be associated with one another. A principal components factor analysis with verimax rotation included positive, negative and disorganized symptoms, TAS, PONS, and AIPSS revealed a three factor solution with

Eigenvalues of 1.542, 1.442 and 0.974 (Table 15). The first factor included positive and disorganized symptoms, the second factor included negative symptoms, the PONS and the TAS, and the third factor included the AIPSS. These factors demonstrate that the two empathy measures did not hang together, and that the emotion perception and alexithymia tasks factored most strongly with negative symptoms. The resulting factors may indicate that the PONS and the AIPSS assess different aspects of empathy, or require use of different neurocognitive abilities. Positive and disorganized symptoms both involve confusion either of internal states or thoughts. The TAS, PONS and negative symptoms (negatively correlated with the factor) might represent an understanding of one‘s own and others‘ emotional experiences. The AIPSS belonged to its own factor which demonstrates the lack of a shared common factor with the other measures in this study. The implications of these factors will be explored further in the discussion section.

Table 15: Factor Analysis of PANSS symptoms, alexithymia, and empathic ability.

Factor 1 Factor 2 Factor 3

PANSS positive 0.712 0.254 -0.108

PANSS negative -0.032 -0.731 0.426

PANSS disorganized 0.730 -0.182 -0.444

TAS 0.342 0.498 0.287

PONS -0.350 0.749 0.117

AIPSS 0.512 0.040 0.698

Relationships Between Symptoms, Alexithymia, and Clinician-Rated Negative Emotionality.

Given the significant correlations of clinician-rated negative emotionality with overall symptom severity (excluding depression and anxiety scores), positive symptoms, and alexithymia, linear regression were conducted to consider alexithymia as a mediator in the relationships between symptoms and clinician-rated negative emotionality. When alexithymia was entered into either model, significant mediations were not found (Tables 16 and 17). We also considered that clinician-rated negative emotionality might influence rates of alexithymia and serve as a mediator in the relationship between symptoms and alexithymia. When clinician-rated negative emotionality was entered into the model, the relationship between overall symptom severity and alexithymia was reduced (β = 0.166 to β = -0.030;

Boot (5000) CI 95% = 0.0358 and 0.2742), and significant mediation was found (R² = 0.073, adjusted R²

= 0.018, F (2, 106) = 4.182, p < 0.05; Table 18). When clinician-rated negative emotionality was entered into the model, the relationship between positive symptoms and alexithymia was reduced (β = 0.207 to β

= 0.117; Boot (5000) CI 95% = 0.0154 and 0.9192), and significant mediation was found (R² = 0.076, adjusted R² = 0.060, F (2, 114) = 4.702, p < 0.05; Table 19). This indicates that clinician-rated negative

emotionality accounted for some of the variance in the relationships of overall and positive symptom severities to alexithymia.

Table 16: Regression—PANSS total symptoms (IV), TAS (M), and clinician-rated negative emotionality (DV).

B SE B Beta t (p-value) R² (adj F (2, 106) R²)

IV on DV 0.103 0.011 0.676 9.489 (0.000)

IV on M 0.125 0.072 0.116 1.737 (0.085)

M on DV 0.033 0.014 0.162 2.286 (0.024)

IV on DV (w 0.099 0.011 0.649 9.163 0.483 49.416 M) (0.000) (0.473) (0.000)

Boot CI -0.0008 and 0.0021

Table 17: Regression—PANSS positive symptoms (IV), TAS (M), and clinician-rated negative emotionality.

B SE B Beta t (p-value) R² (adj F (2, 114) R²)

IV on DV 0.414 0.078 0.443 5.297 (0.000)

IV on M 0.945 0.416 0.207 2.269 (0.025)

M on DV 0.035 0.017 0.171 2.029 (0.045)

IV on DV (w 0.381 0.079 0.407 4.833 0.224 16.470 M) (0.000) (0.211) (0.000)

Boot CI -0.0035 and 0.0912

Table18: Regression—PANSS total symptoms (IV), clinician-rated negative emotionality (M), and TAS (DV).

B SE B Beta t (p-value) R² (adj F (2, 106) R²)

IV on DV 0.125 0.072 0.166 1.737 (0.085)

IV on M 0.103 0.011 0.676 9.489 (0.000)

M on DV 1.434 0.627 0.290 2.286 (0.024)

IV on DV (w -0.023 0.096 -0.030 -0.240 0.073 4.182 M) (0.811) (0.018) (0.018)

Boot CI 0.0358 and 0.2742

Table 19: Regression—PANSS positive (IV), clinician-rated negative emotionality (M), and TAS (DV).

B SE B Beta t (p-value) R² (adj F (2, 114) R²)

IV on DV 0.945 0.416 0.207 2.269 (0.025)

IV on M 0.414 0.078 0.443 5.297 (0.000)

M on DV 0.995 0.490 0.204 2.029 (0.045)

IV on DV (w 0.533 0.458 0.117 1.163 0.076 4.702 M) (0.247) (0.060) (0.011)

Boot CI 0.0154 and 0.9192

Associations of Symptoms, Alexithymia, Empathy, and Social Functioning with Self-Reported

Negative Emotion.

Pearson correlations were conducted looking at the relationships of self-reported negative emotionality to symptom severity, alexithymia, empathic ability and social functioning. Both the BDI and self-reported negative emotionality (a composite score computed from standardized z-scores on the

BDI and STAI) were significantly related to overall symptom severity (excluding PANSS anxiety and

PANSS depression items) and positive symptoms; a trend relationship was found between negative symptoms and the BDI. Alexithymia was significantly related to self-reported depression and self- reported negative emotionality (Table 20). Both the SFS engagement and interpersonal subscales were significantly related to self-reported depression and negative emotionality (Table 20). No significant relationships were found between self-reported depression and empathic ability. Self-reported anxiety was not significantly related to any of the symptom variables, alexithymia, empathic ability, or social functioning; self-reported anxiety and self-report depression were also unrelated.

Table 20: Correlations between PANSS symptom variables, alexithymia, empathic ability, social functioning, and self-report negative emotionality.

BDI STAI Self-report Emotion

PANSS Total 0.446** 0.036 0.375** (excluding depression and anxiety)

PANSS Positive 0.420** -0.033 0.309**

PANSS Negative 0.182† -0.151 0.032

PANSS Disorganized -0.136 -0.163 0.018

TAS Total 0.421** 0.014 0.351**

PONS 0.147 0.161 0.264*

AIPSS 0.135 -0.044 0.065

Empathic Ability 0.171 0.074 0.206†

SFS Engagement -0.411** 0.154 -0.199†

SFS Interpersonal -0.447** 0.134 -0.299*

STAI -0.142

Self-report Emotion 0.658** 0.653**

**p< 0.01, *p< 0.05, †p< 0.1 PANSS = Positive and Negative Syndrome Scale for Schizophrenia; TAS = 20-Item Toronto Alexithymia Scale; PONS = Profile of Nonverbal Sensitivity Task; AIPSS = Assessment of Interpersonal Problem Solving Scale; BDI = Beck Depression Inventory; STAI = State-Trait Anxiety Inventory; Self-report Emotion = (standardized z-scores of BDI + STAI)

Influence of Self-Reported Negative Emotion on the Relationship Between Symptoms and

Empathy.

Given the relationship between self-reported depression, symptom variables and alexithymia, linear regressions were conducted to consider whether TAS mediated the relationship between 1) overall symptom severity (excluding PANSS anxiety and PANSS depression) and the BDI, and 2) positive symptoms and the BDI. When alexithymia was entered into either model, the relationships between symptoms and the BDI were not significantly reduced and mediations were not found (Table 21 and 22).

We also considered that negative emotionality might influence levels of alexithymia, and entered self- reported depression as a mediator in the relationship between symptom severity and alexithymia. When the BDI was entered into the model, the relationship between overall symptom severity (excluding

PANSS anxiety and PANSS depression) and alexithymia was reduced (β= 0.099 to β= -0.088; Boot

(5000) CI 95% = 0.0442 and 0.2708), and significant mediation was found (R²= 0.122, adjusted R²=

0.098, F (2, 73) = 5.095, p < 0.01; Table 23). When the BDI was entered into the model, the relationship between positive symptoms and alexithymia was reduced (β= 0.227 to β= 0.095; Boot (5000) CI 95% =

0.0930 and 1.3975), and significant mediation was found (R²= 0.136, adjusted R²= 0.114, F (2, 79) =

6.236, p < 0.01; Table 24). This indicates that self-reported depression accounted for some of the variance in the relationships between overall and positive symptoms severities and alexithymia; this suggests the relative importance of negative emotion (i.e. self-reported depression and clinician-rated negative emotionality) in explaining why symptoms are related to levels of alexithymia.

Table 21: Regression—PANSS total symptoms (IV), TAS (M), and BDI (DV).

B SE B Beta t (p-value) R² (adj F (2, 73) R²)

IV on DV 0.344 0.081 0.443 4.248 (0.000)

IV on M 0.125 0.072 0.166 1.737 (0.085)

M on DV 0.279 0.090 0.307 3.105 (0.003)

IV on DV (w 0.325 0.077 0.418 4.220 0.290 14.897 M) (0.000) (0.270) (0.000)

Boot CI -0.0243 and 0.0942

Table 22: Regression—PANSS positive (IV), TAS (M), and BDI (DV).

B SE B Beta t (p-value) R² (adj F (2, 79) R²)

IV on DV 1.921 0.473 0.413 4.062 (0.000)

IV on M 0.945 0.416 0.207 2.269 (0.025)

M on DV 0.258 0.093 0.279 2.782 (0.007)

IV on DV (w 1.626 0.466 0.350 3.486 0.245 12.814 M) (0.001) (0.226) (0.000)

Boot CI -0.0149 and 0.8190

Table 23: Regression—PANSS total symptoms (IV), BDI (M), and TAS (DV).

B SE B Beta t (p-value) R² (adj F (2, 73) R²)

IV on DV 0.077 0.090 0.099 0.854 (0.396)

IV on M 0.345 0.070 0.490 4.90 (0.000)

M on DV 0.423 0.138 0.384 3.062 (0.003)

IV on DV (w -0.068 0.097 -0.088 -0.702 0.122 5.095 M) (0.485) (0.098) (0.008)

Boot CI 0.0442 and 0.2708

Table 24: Regression—PANSS positive (IV), BDI (M), and TAS (DV).

B SE B Beta t (p-value) R² (adj F (2, 79) R²)

IV on DV 1.142 0.547 0.227 2.089 (0.040)

IV on M 1.926 0.460 0.420 4.187 (0.000)

M on DV 0.345 0.124 0.320 2.782 (0.007)

IV on DV (w 0.478 0.576 0.095 0.830 0.136 6.236 M) (0.409) (0.114) (0.003)

Boot CI 0.0930 and 1.3975

Discussion.

Summary of Findings.

This study explored the relationship between symptoms of schizophrenia and empathic ability, considering alexithymia as a mediator in the relationship. The results showed that the hypotheses were partially supported: total symptom severity was related to alexithymia, emotion perception, and social functioning; positive symptoms were related to alexithymia and social functioning; disorganized symptoms were related to the PONS; and alexithymia was related to social functioning. Counter to our hypotheses, the two measures of empathy, the PONS and the AIPSS, were not significantly related to each other, alexithymia, or social functioning; there was, however, a positive-trend relationship between alexithymia and the PONS. Relationships were found between negative affect, alexithymia, social functioning, and all symptoms of schizophrenia, except for disorganized symptoms. In addition, neurocognitive abilities, namely general cognitive functioning and executive functioning, were related to both the PONS and the AIPSS.

Hypothesized mediations were conducted, but failed to find significant mediation for any of the models. Hypothesized mediations that included covariates were also conducted, but none of the models was improved. Exploratory analyses found that self-reported depression was related to alexithymia, social functioning, overall symptom severity, and positive symptoms of schizophrenia. Given the significant associations between alexithymia, self-reported depression, clinician-rated negative emotionality, overall symptoms, and positive symptoms, mediations were conducted; mediations were significant for emotion variables contributing to the relationship between symptoms and alexithymia.

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Other analyses were conducted in an exploratory manner, and will be discussed below as they pertain to the significant findings.

Interpretation of Findings.

Consistent with Hypotheses.

As mentioned above, we found significant relationships between symptom severity and social functioning. Persons with greater overall symptom severity and positive symptoms engaged in fewer social activities, such as seeing friends or talking to family on the phone; were less able to engage in activities on their own, such as household chores and grocery shopping; and spent less time on recreational activities, such as crafts or going to the movies. Previous studies have found similar relationships between impaired interpersonal skills and overall symptom severity, and people with schizophrenia have performed significantly worse on social skills tasks than a healthy control group

(Pinkham & Penn, 2006). Other researchers have found that severity of positive symptoms was negatively related to subjective quality of life (Addington & Addington, 1999).

Positive relationships between overall symptom severity, positive symptoms, and alexithymia were found. These findings are consistent with previous studies, as many researchers have documented a significant relationship between symptoms of schizophrenia and alexithymia (Cedro et al., 2001; Serper

& Berenbaum, 2008); also, people with schizophrenia tend to have greater severity of alexithymia than other psychiatric populations (Spitzer et al., 2007). In the present study, participants with higher frequency and severity of hallucinations and delusions had a more difficult time both identifying their own emotions, such as distinguishing between two different feelings, and describing their emotions to others, such as finding the right words to explain how they felt.

The PONS, an empathy measure of emotion perception, was significantly related to disorganized symptoms in this study. Persons with greater cognitive disorganization, evidencing symptoms such as loose associations between ideas, were less able to correctly identify the mood state and situational context of a woman presented in short audio and video clips. Other researchers have found relationships between disorganized symptoms and emotion perception, perhaps due to underlying cognitive impairments affecting both symptoms and emotion recognition abilities (Lee, 2007; Sarfati, Hardy-Bayle,

Beche, & Widlocher, 1997). Overall symptom severity and negative symptoms were related in the expected direction to the PONS at the level of a trend. Shur and colleagues (2008) found that overall symptoms of schizophrenia accounted for more than 50% of the variance on empathy tasks, indicating the impact of symptom severity on empathic ability. Other researchers, however, have not found significant relationships between symptom severity and empathy tasks (Derntl et al., 2009), indicating that the nature of the relationship between empathy and symptom variables is yet unclear.

Higher levels of alexithymia were also related to more impaired social functioning, a relationship that has been demonstrated in other populations (Honkalampi, Saarinen, Hintikka, Virtanen, &

Viinamaki, 1999; Sayer et al., 2001; Verissimo, Mota-Cardoso, & Taylor, 1998), but has not, to the author‘s knowledge, yet been documented in people with schizophrenia. However, the same conceptual reasoning, that people with difficulty identifying and describing their emotions to others have a more difficult time interacting with others in a social manner, might apply equally to people with schizophrenia as it does to other populations. The items on the social functioning scale inquire about engaging in activities and conversing with others, and while this may be possible to do without sharing emotional information, a person with high alexithymia may come across as cold or distant, thus impacting their social interactions.

Contrary to Hypotheses.

The PONS and AIPSS were not related to each other. One explanation is that the two measures were looking at different aspects of empathy that are not be highly related to each other. The PONS is a measure of emotion perception, while the AIPSS assesses perspective taking abilities. In the current study, performance on the PONS, involving correct identification of social actions from auditory and visual emotional clues, was not associated with identification of a social problem occurring between two individuals in the AIPSS videos. Similarly, Brune (2005) did not find a significant relationship between performance on an emotion recognition task using still pictures and ToM tasks requiring appreciation of another person‘s mental state. Unlike the present study, Derntl and colleges (2009) found a significant relationship between emotion recognition and perspective taking tasks for a patient group, but not for a healthy control group. Their findings indicate that the relationships between different types of empathic abilities may not be entirely stable and consistent. Further, Shur et al. (2008) found a different area of the brain was used on an emotion perception task than in a perspective taking task, indicating neurological distinctions between these empathic abilities.

It should also be noted that the AIPSS was not highly related to any of the variables of interest, except for executive functioning; however, non-significant correlations with other neurocognitive variables were in unexpected directions. The AIPSS may have been a more complicated task in comparison to the others, requiring participants to pay attention to the vocal inflections and content of two characters‘ speech and the setting in which the social interaction took place, and to ―put themselves in the shoes‖ of one of the characters; participants were then expected to recall previous information in order to determine if a social problem occurred, and were asked to describe the observed problem. A previous study found that high scores on the AIPSS were related to visual vigilance and recognition of a learned word list, further demonstrating the possible overlap of some cognitive abilities and performance on the

AIPSS (Corrigan & Toomey, 1995). Unfortunately, memory and learning tasks were not administered in

this study; more research is needed to determine if the AIPSS is a pure empathic ability measure, or something more neurocognitively based. Similar to the present study, Corrigan and Toomey (1995) also did not find relationships between the AIPSS and symptom severity.

Neither empathy task related to social functioning. Addington and Addington (2000) also found that social functioning was not related to the processing of information on the AIPSS; social functioning scales assess the frequency of social behaviors, while empathy tasks, such as the AIPSS, are designed to measure the quality and competence of those behaviors. Another study found that performance on the

PONS was related to some aspects of functioning, namely work functioning and independent living, but was not related to broader social abilities, such as seeing friends (Sergi, Rassovsky, Nuechterlein, &

Green, 2006). Horan and colleagues (2009) considered the effect of social skills training and found that emotion perception improved, but perspective taking ability did not; additionally, patients in the social skills group and in the control group reported equal satisfaction with treatment in regard to their daily functioning, indicating that social skills training may not provide benefits to daily life above and beyond other interventions. It appears that the relationship between empathic ability and social functioning is yet to be well understood.

An important consideration is the methodology used in the empathy versus social functioning tasks. Both the PONS and the AIPSS were performance-based tasks in which participants watched videos and then either identified the emotional state of an actress, or put themselves ―in the shoes‖ of a person with a social problem. The Social Functioning Scale was conducted as an interview in which participants were asked how frequently they saw friends or engaged in a hobby, and how easy or difficult it was for them to do their own shopping and manage public transportation. It is possible that some participants over-reported the frequency and ease with which they engaged in social activities, but actually performed poorly on tasks related to social interactions. Another possibility is that the empathy

measures have limited ecological validity, causing some participants to seem less adept at social interactions than they are in actuality.

Alexithymia was not significantly related to empathy in this sample, although there was a positive trend between the TAS and the PONS. These findings are consistent with those of Koelkebeck and colleagues (2010), who found that use of ToM vocabulary words was positively related to difficulty identifying emotions on the TAS. There are a few possible reasons the unexpected positive relationships were found in both our study and that of Koelkebeck et al. (2010). First, the TAS is a self-report measure that requires some degree of insight in order to respond appropriately; a person must self-reflect on whether he can identify and differentiate between his emotions, such as knowing when he feels sad versus scared, and then determine if he can describe those feelings to others. A person with limited insight may not provide accurate and useful information on self-report measures, because he lacks the requisite self- knowledge to do so, the exact topic explored by the TAS.

A second possibility is that those who indicated higher levels of alexithymia on the TAS may actually be more aware of their difficulties; those with greater awareness of difficulties may therefore put forth more effort on performance-based tasks. Also, in a paradoxical sense, a person with better awareness of his own emotions may be more likely to notice limitations in this awareness, i.e. knowledge of one‘s limitations may reflect better social cognition than does ignorance of them. However, ―lack of awareness of emotions‖ is the definition of alexithymia; therefore, this hypothesis is conceptual rather than something that has been explored in research.

Third, empathic ability may not be highly related to knowledge of one‘s own emotions.

According to the Simulation Theory of empathy, mirror neurons function to create feelings of empathy by allowing subjects to simulate the experiences of others (Heal, 1996), which may not necessarily be based on understanding of one‘s own emotions. It is possible that people with alexithymia have a difficult time with the verbal identification and description of their emotions, but are still able to experience emotional

states, either of the self or as the simulation of another‘s; emotion, in this sense, is experienced as simple physiological states independent of vocabulary. Research and anecdotal reports have shown that an infant cries in response to another infant‘s cries, almost in a contagious fashion (Simner, 1971). It is unclear whether the second infant, crying in response to the first, is aware of his own emotional state, or even if the infant is experiencing an emotional state at all (Sagi & Hoffman, 1976). Hoffman (2000) posits that contagious crying is the first step in empathizing with others. If so, Simulation Theory may not require knowledge of the self in order to have knowledge of another. In other words, perhaps mirror neurons work independent of a conscious and verbal understanding of one‘s own emotions.

Influence of Covariates.

Clinician ratings of negative emotion, including symptoms of depression and anxiety, were related to overall schizophrenia symptom severity and positive and negative symptom clusters. Persons with more frequent and more extensive hallucinations and delusions experienced and reported both greater amounts of anxiety, such as worried thoughts and a racing heart, and depression, such as often being tearful and feeling sad. Other studies have found high levels of co-morbidity between schizophrenia and depressive symptoms (Becker, 1988; Nkam et al., 1997; Siris et al., 2001), and symptoms of anxiety (Cosoff & Hafner, 1998; Nkam et al., 1997; Tibbo, Swanson, Chue, & Lemelledo,

2003). Alexithymia was also related to severity of clinician-rated negative emotion, which has been found in other studies (Cedro et al., 2001; Nkam et al., 1997). Negative emotion and social functioning were negatively related, as would be expected, indicating that those with greater depressive and anxiety symptoms were less likely to engage and interact with others in a social environment. The influence of mood symptoms on decreased social functioning, whether related to lack of skill or rejection by others, is well-established (Blanchard, Mueser, & Bellack, 1998; Coyne, Thompson & Palmer, 2002; Joiner,

Alfano & Metalsky, 1992; Segrin & Abramson, 1994).

Empathic ability in this study, as determined on performance tasks, was not related to negative emotion, indicating that a person‘s internal mood state did not necessarily affect his ability to successfully recognize the emotional states and social actions of others. It should be noted that, although it was not a significant relationship, empathy was positively associated with negative emotion, indicating persons with better empathic ability experienced more symptoms of depression and anxiety. Research has shown that some people experiencing symptoms of depression actually have a more accurate interpretation of the self and social situations, a phenomenon that has been termed ―depressive realism‖ (Alloy & Abramson,

1979; Watson & Clark, 1984). Some degree of anxiety may also cause a person to be more acutely aware of negative information (Mogg & Bradley, 1998), such as tension between roommates or a person being critical of another; these types of negative situations were common examples in the measures of empathy used in this study. Thus, those with mild symptoms of depression and anxiety may have had a slight advantage on the empathic ability tasks used in this study.

A positive trend was found between the SILS and the PONS, indicating that people who performed better on a general cognitive ability test also perceived emotion more accurately on the audio/video task. Other studies have found a relationship between verbal ability and performance on emotion perception (Pinkham & Penn, 2006) and social comprehension tasks (Brune, 2005). Koelkebeck et al. (2010) also found a positive relationship between use of ToM-related vocabulary and performance on a reading task, often used as a proxy measure for pre-morbid IQ. The WCST was negatively related to both the PONS and the AIPSS, indicating that poor performance on the empathy tasks was associated with impaired executive functioning.

Two of the neurocognitive abilities considered in this study, general cognitive ability and executive functioning, were significantly related to empathic ability. Specifically, persons who performed better on a task of general cognitive ability, containing verbal and abstraction components, also performed better on the PONS. Executive dysfunction, involving difficulty reasoning and manipulating

information, was negatively related to both the PONS and the AIPSS in this study; people who made fewer card-sort match errors were better at correctly identifying emotions and social problems. Both the

WCST and the AIPSS can be conceptualized as problem solving tasks, one measuring problems of reasoning and the other problems of social interactions, and these findings are in line with other studies

(Brune, 2005; Nomi et al., 2008; Pinkham & Penn, 2006).

Interestingly, none of the neurocognitive measures was related to the TAS. These findings may indicate that the process of understanding and identifying one‘s own emotions is an ability separate from other neurocognitive functions. It is also possible that the measures used in the present study, particularly the TAS, may not have been appropriate for an outpatient schizophrenia sample. Only one study, to the author‘s knowledge, has reported a significant relationship between neurocognitive ability and alexithymia (Corcoran & Frith, 2003), while most other studies considering alexithymia in a schizophrenia sample have not included neurocognitive measures (Cedro et al., 2001; Serper &

Berenbaum, 2008). Studies looking at neurocognitive ability and alexithymia in non-schizophrenia samples have been mixed, some finding associations with emotional clarity alone (Koven & Thomas,

2010), others indicating that alexithymia is more highly related to verbal (versus performance-based) cognitive assessments (Galderisi et al., 2008).

None of the neurocognitive measures was related to social functioning abilities. There has been a great deal of research looking at whether social cognition is an aspect of, or separate from, neurocognition; while the debate continues, it appears that some neurocognitive abilities, such as verbal ability and general IQ, can influence social cognition (Brune, 2003; Doody, Gotz, Johnstone, Frith, &

Cunningham-Owens, 1998), although not all studies have found this to be true (Brune, 2005; Greig,

Bryson, & Bell, 2004). The relationship between neurocognition, social cognition, and social functioning is not so straightforward; to demonstrate, a study found that children with Down syndrome were highly

sociable, but significantly impaired in their emotion recognition abilities (Kasari, Freeman & Hughes,

2001). Further, having intact cognitive abilities does not confer sociability (Dauber & Benbow, 1990).

Planned Mediations.

None of the planned mediations looking at the impact of alexithymia on the relationships between symptoms and empathy was significant, nor were any of these mediations improved with the addition of third variables and covariates. These findings are not surprising given the lack of significant relationships between the variables of interest. The only other study, to the author‘s knowledge, that has looked at symptoms, alexithymia, and empathic ability in people with schizophrenia also failed to find a significant relationship between alexithymia and empathic ability in a patient group (Koelkebeck et al., 2010). More research is needed to better understand the relationship, or lack thereof, between alexithymia and empathic ability in the schizophrenia population.

Exploratory Findings.

Social Functioning.

We hypothesized that alexithymia would impact the relationships between symptoms and social functioning and explain some of their relationships. Although research has shown that highly symptomatic individuals with schizophrenia tend to be socially isolated and withdrawn, and we reasoned that poor knowledge of one‘s own emotions may prevent or inhibit a person from being sociable, we did not find significant mediations. It is possible that other factors, such as stigma about mental illness and symptoms of paranoia, influence the ability and willingness of persons with schizophrenia to socialize

(Penn, Kohlmaier & Corrigan, 2000). Such factors may have more of an impact on sociability than an individual‘s emotional knowledge.

Suitability of the TAS.

To determine whether non-significant findings were related to problems with the measures used, we looked at the relationships between all variables of interest and individual facets of alexithymia: identifying emotions and describing emotions. The strongest positive relationships were found between identifying emotions and overall and positive symptom severity. People who indicated difficulty identifying their own emotions had more severe hallucinatory and delusional experiences. Identifying emotions was also related to the PONS and social functioning. Describing emotions was positively related to the PONS, although not to the other measures. Looking at individual facets of alexithymia did not indicate mediations between symptoms of schizophrenia and social functioning.

To test the validity of the TAS in this population, we looked at item-to-scale correlations for the

TAS to determine if the measure itself was problematic. Results indicated an adequate alpha, although eight individual items had low correlation coefficients. Removal of the eight lowest items, however, did not change the relationships among alexithymia, symptoms, empathic ability, and social functioning.

These findings indicate the relatively stable nature of the TAS in the present study. As mentioned earlier, the TAS has been used frequently with people with schizophrenia, as well as other populations, but there may be problems with administering a self-report task to determine insight into a person‘s knowledge of his emotions. Participants with high degrees of alexithymia may have a difficult time truly reporting on their ability to identify and describe their feelings, a potential problem that has been highlighted by other researchers (Lundh, Johnsson, Sundqvist, & Olsson, 2002).

To further explore the influence of insight, we compared participants who performed well on an abstraction test with those who performed poorly. The high-performance group had a significant positive relationship between alexithymia and emotion perception, while the group demonstrating poor abstract thinking abilities did not have a significant relationship between alexithymia and emotion perception.

These findings suggest that abstract thinking may be an important component to understanding the relationship between alexithymia and emotion perception. People with greater insight and understanding of their emotions may be more aware of the complicated nature of emotions and less satisfied with their understanding, as indicated on the TAS, and therefore put forth more effort toward understanding others, reflected by their performance on the PONS. Likewise, those who are unskilled at emotion perception, evidenced by poor performance on the PONS, may also be unaware of their deficits, self-reporting no alexithymia. This phenomenon, known as ―unskilled and unaware,‖ has been discussed previously in research of appraisal of one‘s own skills (Kruger & Dunning, 1999), but may apply equally to appraisal of one‘s own emotional understanding, alexithymia, and should be explored further.

Effect of Groups.

We considered the possibility that looking at alexithymia and empathic ability as continua prevented significant relationships between the variables from emerging. Therefore, we looked at high and low-scoring groups that were one standard deviation or more from the mean, in each respective direction, for both the TAS and the PONS. Looking at more extreme groups of scorers can sometimes reveal relationships otherwise obscured. The results indicated that high levels and low levels of alexithymia were unrelated to empathic ability. Similarly, participants who performed well versus poorly on the PONS were equally likely to self-report alexithymic features. It should be noted that we reduced our statistical power for finding relationships due to the smaller sample sizes in these analyses.

Suitability of the PONS and the AIPSS.

We considered that the empathy measures used may have impacted our findings. The PONS has been found to correlate with other measures of emotion perception, included in a larger study, which demonstrates its construct validity (Docherty, Unpublished data). The PONS poses a more difficult task than other empathy tasks, requiring participants to draw conclusions from very brief (2 second) video clips of facial expression, body language, and voice inflection to identify the social action being portrayed. The difficulty of the PONS may have caused participants to attend more and put forth more effort than they did on other tasks, such as on the TAS. The relationship between the PONS and TAS may also be an artifact of the data given that multiple correlations were conducted, increasing the risk of type II error. Other studies, aside from Koelkebeck et al. (2010), have not looked at the relationship between these two concepts in schizophrenia. Therefore, more research is needed to fully consider the relationships between different empathic abilities and alexithymia in the schizophrenia population.

Unlike the PONS, the AIPSS was not shown to relate to any other measures of empathic ability in a larger study (Docherty, Unpublished data). The AIPSS may have been an inappropriate measure for the purposes of the present study, given its lack of significant relationships with almost any of the other variables, aside from some of the neurocognitive variables; it is possible the AIPSS was measuring a different ability than we intended, i.e. something other than perspective taking ability.

Factor Analysis.

A factor analysis indicated that the AIPSS fell into a factor of its own, separate from all the symptom variables, the PONS, and the TAS. A second factor including positive and disorganized symptoms may represent internal state confusion. Positive symptoms can result from confusing internal

stimuli for external experiences, while disorganized symptoms might be considered confused thought processes, i.e. jumping from one idea to another without logical or coherent directionality. A third factor that emerged included the TAS and PONS, both of which involve understanding and recognition of emotions. As has been discussed previously, those who were aware of their deficits might have compensated and tried harder to understand others. Negative symptoms were negatively correlated with this factor, which may indicate that participants with a better understanding of others‘ emotions were less socially withdrawn and isolated. Seen from a different angle, participation in a social milieu may facilitate other-emotion recognition, and highlight self-emotion difficulties; those who are more social improve their skills with others and better identify their own deficits.

Influence of Negative Emotion.

As discussed previously, clinician-rated negative emotion was related to symptom severity, alexithymia, and social functioning. We were also interested in the impact of self-reported negative emotion on these same variables, as it might differ from that of clinician-rated measures. Of the two measures used, only a self-report depression measure, the BDI, was related to other variables of interest: the BDI was significantly related to overall symptom severity, positive and negative symptoms, alexithymia, and social functioning. The lack of significant relationships with the self-report anxiety measure, the STAI, may have been due to the mix of schizophrenia and schizoaffective disorder participants; nearly all of the relationships of variables with clinician-rated depression were greater than were the associations with clinician-rated anxiety. Symptoms of depression are common in people with schizophrenia (Hafner et al., 2005). Schizophrenia is a mental disorder with a lot of associated stigma; it tends to be an isolating disorder, either by personal choice or social shunning, and many persons with schizophrenia have difficulty maintaining employment, social relationships, and other areas of functioning (Hooker & Park, 2002; Howard et al., 2000; Neumann & Walker, 1998). Work, friendships,

and independence can have enormous impacts on a person‘s self-worth and emotional state (Eklund,

Hansson & Bejerholm, 2001; Sensky et al., 2000). Self-reported depression was also strongly related to alexithymia, a correlation that has been found consistently in various populations (Honkalampi, Hintikka,

Tanskanen, Lehtonen, & Viinamaki, 2000; Parker, Bagby & Taylor, 1991). The negative relationship between depression and social functioning has been demonstrated in previous studies, i.e. those who are depressed tend to withdraw from others (Herschfeld et al., 2000; Honkalampi et al., 2000).

Given the relationships between symptoms of schizophrenia and alexithymia, clinician-rated negative emotionality and self-reported depression, we further explored the nature of these relationships.

We considered that alexithymia might mediate the relationship between symptom severity and negative emotionality because participants who are unable to identify and describe their emotions might feel overwhelmed by negative emotion, which they would then be unable to address given their lack of specific knowledge regarding emotions. Therefore, mediational models considered alexithymia as a mediator in the relationships between 1) overall symptom severity and clinician-rated negative emotionality, 2) positive symptoms and clinician-rated negative emotionality, 3) overall symptom severity and self-reported depression, and 4) positive symptoms and self-reported depression. However, significant mediation was not found for any of these models.

We then theorized that negative emotion might impact the relationship between symptom severity and alexithymia; having a great degree of negative emotion may be overwhelming and cause the person to detach from their emotions, resulting in the experience of alexithymia. Following this line of reasoning, we conducted mediational analyses with both clinician-rated negative emotionality and self-reported depression as mediators in the relationships between overall and positive symptom severities and alexithymia. All models had significant mediation, indicating that both objective negative emotionality and subjective depression were important for understanding how symptoms of schizophrenia related to alexithymia. These findings are not entirely unexpected. We had initially hypothesized that negative

emotion would be related to symptoms and alexithymia, as has been demonstrated in previous research

(Cedro et al., 2001; Parker, Bagby & Taylor, 1991; Serper & Berenbaum, 2008); we considered the possibility that negative emotion might influence relationships between variables and therefore looked at negative emotionality as a third variable in the original analyses.

Based on our findings, it appears that alexithymia may be, paradoxically, emotion-driven, perhaps brought on or intensified by an inability to cope with high levels of negative emotion. A similar idea was hypothesized by Keltner and Kring (1998) who posited that people with schizophrenia have intact, and sometimes more intense, experiences of emotion, but are unable to express those emotions to others. The inability to express what one is feeling to another person might prevent the person with schizophrenia from receiving support or sympathy from others, thus depriving him of important social interactions

(Keltner & Kring, 1998). Unfortunately, the present study did not include measures of positive emotion, and therefore it was not possible to compare negative and positive emotionality in alexithymia. Previous studies, however, have documented the tendency for people with schizophrenia to experience high levels of trait-negative affect and low levels of trait-positive affect, mood states that are related to symptoms of anhedonia and poor social functioning (Blanchard et al., 1998). Future research should consider the impact of both negative and positive affect on alexithymia in a schizophrenia population.

It has been shown previously that people with schizophrenia experience many other psychological symptoms, such as anxiety, depression, and poor social functioning; schizophrenia is an illness that impacts a person‘s ability to differentiate between reality and fantasy, and is stigmatizing and isolating (Bean, Beiser, Zhang-Wong, & Iacono, 1996; Birchwood & Iqbal, 1998); it is also an illness that is difficult to manage even with antipsychotic medication and therapy (Lehman et al., 2004; Swartz et al.,

2007). The confusion of internal states, including emotions, thoughts, and experiences, is intimately linked with poor social functioning and therefore is an important area of continued research and an appropriate target for treatment.

Limitations.

A number of factors must be taken into consideration in order to appropriately interpret the findings of this study. These include the restricted range of some of the variables, the measures used, unforeseen third variables, and a large number of comparisons, some of which were post hoc.

A few of the variables had restricted ranges which may have impacted our ability to find significance. Some of the variables, such as disorganized symptoms, occurred at high levels in only a small percentage of the sample. Despite the more restricted range, all of the variables were normally distributed and the large sample size provided adequate representation of each of the variables, including disorganized symptoms. Another possible limitation was the measures used, namely the alexithymia and empathic ability measures. Although all the measures used in this study have been used previously in schizophrenia samples, it is possible that they require degrees of cognitive insight that were beyond some of the participants. It is for this reason that future studies should use alternative measures of alexithymia, in addition to the TAS, in order to compare and contrast these findings in this particular population.

Some unforeseen third variables emerged, such as diagnosis and educational level. However, when taken into account in our analyses, these third variables did not seem to impact the results.

Although we took into consideration several potential third variables, it is possible that other third variables not accounted for in this study, or impossible to measure, may have impacted results. It should be noted that this is just the second study (to the author‘s knowledge) that has considered the relationships among symptoms of schizophrenia, alexithymia, and empathic ability. Future research should continue to explore these relationships, as well as those among symptoms, alexithymia, and negative emotion.

Finally, multiple comparisons between variables were made, many of which were conducted post hoc as exploratory analyses. The risk of Type II error increases as the number of comparisons increases;

it is possible we erroneously concluded that some relationships were significant when they were, in fact, the result of Type II error. Caution should always be exerted when interpreting exploratory results as well. The interesting relationships found in the present study between alexithymia and negative emotionality should be further explored to better understand the significance and meaning of our findings.

Conclusions.

In summary, our hypotheses were partially supported: overall symptom severity and positive symptoms were related to alexithymia, negative emotion, and social functioning, but were not related to empathic ability. Contrary to the predictions, empathic ability was related to alexithymia in a positive direction, although not significantly, and alexithymia did not mediate the relationships between symptoms and empathic ability. Exploratory analyses found that both clinician-rated negative emotionality and self- reported depression significantly mediated the relationships between overall and positive symptom severities and alexithymia, suggesting that negative emotion may be an important component to understanding levels of alexithymia in people with schizophrenia. However, these post-hoc findings in the context of multiple comparisons should be viewed as heuristic rather than in any way conclusive.

There were some limitations to this study including the restricted range of variables, measures used, and multiple comparisons conducted which may have impacted the results. Future studies should assess these same hypothesized relationships of symptoms of schizophrenia, alexithymia, and empathic ability using different measures, while further exploring the role of negative emotion in the aforementioned relationships.

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Appendix A: Mediation tables between symptom severity, alexithymia, and empathic ability.

Regression—PANSS Total (IV), TAS (M), Empathy (DV).

B SE B Beta t (p-value) R² (adj R²) F (2, 57) Boot CI

IV on DV 0.004 0.012 0.046 0.349 (0.729)

IV on M 0.112 0.080 0.140 1.403 (0.164)

M on DV 0.010 0.015 0.093 0.701 (0.486)

IV on DV 0.004 0.012 0.038 0.286 0.011 0.306 -0.0026 (w M) (0.776) (0.738) and 0.0072 (-0.024)

PANSS = Positive and Negative Syndrome Scale for Schizophrenia; TAS = Toronto Alexithymia Scale; Empathy = (standardized z-scores of PONS + AIPSS)

Regression—PANSS Total (IV), TAS (M), PONS (DV).

B SE B Beta t (p-value) R² (adj R²) F (2, 93) Boot CI

IV on DV -0.086 0.058 -0.152 -1.494 (0.139)

IV on M 0.112 0.080 0.140 1.403 (0.164)

M on DV 0.099 0.074 0.138 1.350

(0.180)

IV on DV -0.097 0.058 -0.171 -1.671 0.042 2.038 -0.0090 (w M) (0.098) (0.021) (0.136) and 0.0428

PANSS = Positive and Negative Syndrome Scale for Schizophrenia; TAS = Toronto Alexithymia Scale; PONS = Profile of Nonverbal Sensitivity Task

93 94

Regression—PANSS Total (IV), TAS (M), AIPSS (DV).

B SE B Beta t (p-value) R² (adj R²) F (2, 62) Boot CI

IV on DV 0.130 0.120 0.135 1.082 (0.283)

IV on M 0.112 0.080 0.140 1.403 (0.164)

M on DV 0.078 0.143 0.068 0.542 (0.590)

IV on DV 0.123 0.121 0.128 1.018 0.023 0.726 -0.0286 (w M) (0.313) (0.488) and 0.0711 (-0.009)

PANSS = Positive and Negative Syndrome Scale for Schizophrenia; TAS = Toronto Alexithymia Scale; AIPSS = Assessment of Interpersonal Problem-Solving Skills

Regression—PANSS positive symptoms (IV), TAS (M), Empathy (DV).

B SE B Beta t (p-value) R² (adj R²) F (2, 59) Boot CI

IV on DV 0.063 0.075 0.107 0.833 (0.408)

IV on M 0.897 0.440 0.197 2.042 (0.044)

M on DV 0.008 0.015 0.071 0.540 (0.591)

IV on DV 0.054 0.077 0.092 0.696 0.016 0.489 -0.0159 (w M) (0.540) (0.616) and 0.0627 (-0.017)

PANSS = Positive and Negative Syndrome Scale for Schizophrenia; TAS = Toronto Alexithymia Scale; Empathy = (standardized z-scores of PONS + AIPSS)

Regression—PANSS positive symptoms (IV), TAS (M), PONS (DV).

B SE B Beta t (p-value) R² (adj R²) F (2, 95) Boot CI

IV on DV -0.468 0.333 -0.142 -1.404 (0.164)

IV on M 0.897 0.440 0.197 2.042 (0.044)

M on DV 0.102 0.074 0.141 1.372 (0.173)

IV on DV -0.561 0.339 -0.170 -1.655 0.020 1.935 -0.0419 (w M) (0.101) (0.019) (0.150) and 0.3559

PANSS = Positive and Negative Syndrome Scale for Schizophrenia; TAS = Toronto Alexithymia Scale; PONS = Profile of Nonverbal Sensitivity Task

Regression—PANSS positive symptoms (IV), TAS (M), AIPSS (DV).

B SE B Beta t (p-value) R² (adj R²) F (2, 65) Boot CI

IV on DV 0.762 0.698 0.133 1.092 (0.279)

IV on M 0.897 0.440 0.197 2.042 (0.044)

M on DV 0.067 0.144 0.058 0.465 (0.644)

IV on DV 0.689 0.719 0.120 0.958 0.021 0.697 -0.3176 (w M) (0.342) (0.502) and 0.5352 (-0.009)

PANSS = Positive and Negative Syndrome Scale for Schizophrenia; TAS = Toronto Alexithymia Scale; AIPSS = Assessment of Interpersonal Problem-Solving Skills

Regression—PANSS negative symptoms (IV), TAS (M), Empathy (DV).

B SE B Beta t (p-value) R² (adj R²) F (2, 58) Boot CI

IV on DV -0.900 0.445 -0.255 -2.022 (0.048)

IV on M -5.301 2.754 -0.185 -1.925 (0.057)

M on DV 0.004 0.015 0.039 0.298 (0.767)

IV on DV -0.866 0.463 -0.245 -1.873 0.065 2.057 -0.2979 (w M) (0.298) (0.034) (0.137) and 0.2262

PANSS = Positive and Negative Syndrome Scale for Schizophrenia; TAS = Toronto Alexithymia Scale; Empathy = (standardized z-scores of PONS + AIPSS)

Regression—PANSS negative symptoms (IV), TAS (M), PONS (DV).

B SE B Beta t (p-value) R² (adj R²) F (2, 95) Boot CI

IV on DV -4.575 2.061 -0.221 -2.220 (0.029)

IV on M -5.301 2.754 -0.185 -1.925 (0.057)

M on DV 0.062 0.074 0.086 0.839 (0.404)

IV on DV -4.204 2.111 -0.203 -1.992 0.056 2.809 -1.5140 (w M) (0.049) (0.036) (0.065) and 0.5354

PANSS = Positive and Negative Syndrome Scale for Schizophrenia; TAS = Toronto Alexithymia Scale; PONS = Profile of Nonverbal Sensitivity Task

Regression—PANSS negative symptoms (IV), TAS (M), AIPSS (DV).

B SE B Beta t (p-value) R² (adj R²) F (2, 64) Boot CI

IV on DV 0.370 4.342 0.011 0.085 (0.932)

IV on M -5.301 2.754 -0.185 -1.925 (0.057)

M on DV 0.111 0.147 0.098 0.756 (0.452)

IV on DV 1.305 4.529 0.037 0.288 0.009 0.289 -4.3673 (w M) (0.774) (0.750) and 1.7255 (-0.022)

PANSS = Positive and Negative Syndrome Scale for Schizophrenia; TAS = Toronto Alexithymia Scale; AIPSS = Assessment of Interpersonal Problem-Solving Skills

Regression—PANSS disorganized symptoms (IV), TAS (M), Empathy (DV).

B SE B Beta t (p-value) R² (adj R²) F (2, 59) Boot CI

IV on DV -0.493 0.511 -0.124 -0.965 (0.338)

IV on M -1.281 3.398 -0.037 -0.377 (0.707)

M on DV 0.012 0.015 0.104 0.809 (0.422)

IV on DV -0.535 0.515 -0.134 -1.040 0.026 0.790 -0.0982 (w M) (0.303) (0.459) and 0.2489 (-0.007)

PANSS = Positive and Negative Syndrome Scale for Schizophrenia; TAS = Toronto Alexithymia Scale; Empathy = (standardized z-scores of PONS + AIPSS)

Regression—PANSS disorganized symptoms (IV), TAS (M), PONS (DV).

B SE B Beta t (p-value) R² (adj R²) F (2, 96) Boot CI

IV on DV -6.862 2.428 -0.276 -2.826 (0.006)

IV on M -1.281 3.398 -0.037 -0.377 (0.707)

M on DV 0.094 0.071 0.128 1.316 (0.191)

IV on DV -6.924 2.420 -0.278 -2.861 0.092 4.889 -0.7883 (w M) (0.005) (0.074) (0.010) and 0.8982

PANSS = Positive and Negative Syndrome Scale for Schizophrenia; TAS = Toronto Alexithymia Scale; PONS = Profile of Nonverbal Sensitivity Task

Regression—PANSS disorganized symptoms (IV), TAS (M), AIPSS (DV).

B SE B Beta t (p-value) R² (adj R²) F (2, 65) Boot CI

IV on DV 2.978 5.004 0.073 0.595 (0.554)

IV on M -1.281 3.398 -0.037 -0.377 (0.707)

M on DV 0.090 0.141 0.079 0.638 (0.526)

IV on DV 2.697 5.046 0.066 0.535 0.012 0.379 -1.1662 (w M) (0.595) (0.686) and 2.1487 (-0.019)

PANSS = Positive and Negative Syndrome Scale for Schizophrenia; TAS = Toronto Alexithymia Scale; AIPSS = Assessment of Interpersonal Problem-Solving Skills