Personality and Individual Differences 113 (2017) 219–222
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Cross-validation of the 20-item Toronto Alexithymia Scale: Results from an Arabic multicenter study Fares Zine El Abiddine a, Hiten Dave b, Said Aldhafri c, Sofián El-Astal d, Fairouz Hemaid e, James D.A. Parker b,⁎ a
Department of Psychology, University of Sidi Bel Abbes, Algeria Department of Psychology, Trent University, Canada Department of Psychology, Sultan Qaboos University, Oman d Al Azhar University, Gaza, Palestine e United Nations Relief and Works Agency-, Gaza, Palestine b c
a r t i c l e
i n f o
Article history: Received 13 December 2016 Received in revised form 28 February 2017 Accepted 8 March 2017 Available online xxxx Keywords: TAS-20 Alexithymia Arabic
a b s t r a c t The Toronto Alexithymia Scale (TAS-20) is a 20-item self-report scale assessing emotional and social competency impairments like difficulty identifying feelings (DIF), difficulty describing feelings (DDF) and externally-oriented thinking (EOT). Despite strong validity and predictive utility in North American and European samples, its validity in Non-Western cultures is still in need of verification. An Arabic version of the TAS-20 was given to a sample (n = 2221) of young adults from 3 Arabic-speaking countries (Algeria, Gaza and Oman), as well as English speaking young adults from Canada (n = 2220). Confirmatory factory analysis indicated good fit of the data from both samples, suggesting that the alexithymia construct can be extended to Arabic populations. The Arabic sample scored significantly higher on the total TAS-20 as well as all subscales and in total TAS-20 scores. This trend was consistent for both men and women and suggests important cultural differences exist in the communication of emotional information. © 2017 Elsevier Ltd. All rights reserved.
1. Introduction The construct of alexithymia has gained increasing attention from health care researchers and providers around the world, including countries where English is not the primary language. Initially conceived of as a primarily psychosomatic health issue(Silfneos, 1973), it is now widely understood as a multidimensional personality construct involving difficulty identifying and discerning feelings and understanding physical sensations of emotional arousal (Taylor, Bagby, & Parker, 1997). Alexithymia also involves an impairment in being able to describe one's feelings to other people and narrow imaginal processes, as well as a very superficial, externally-oriented cognitive style. This personality construct has been linked with an array of health problems, such as problem gambling(Lumley & Roby, 1995), substance abuse and eating disorders (Taylor et al., 1997) and chronic diseases like type-II diabetes (Lemche, Chaban, & Lemche, 2014). It also contributes to other non-clinical lifestyle issues such as loneliness and impaired relationships (Humphreys, Wood, & Parker, 2009; Kokkonen, Karvonen, ⁎ Corresponding author at: Department of Psychology, Trent University, Peterborough, Ontario K9J 7B8, Canada. E-mail address:
[email protected] (J.D.A. Parker).
http://dx.doi.org/10.1016/j.paid.2017.03.017 0191-8869/© 2017 Elsevier Ltd. All rights reserved.
Veijola, & Laksy, 2001), poor nutrition and a sedentary lifestyle (Helmers & Mente, 1999). In light of the widespread health implications, it is important to determine if alexithymia is generalizable across different cultural groups. The twenty-item Toronto Alexithymia Scale (TAS-20) is the most widely used assessment tool for this construct. Despite some criticism that alexithymia may be culture-bound and only fits the worldview of North American and European societal norms (Loiselle & Cossette, 2001), translated versions of the scale show adequate-to-very good fit in a wide range of countries (Taylor, Bagby, & Parker, 2003). In order to further establish its cross-cultural utility, more translations of the TAS-20 need to be assessed in Non-Western cultures. Specifically, validation should continue to be done in “collectivist” cultures where religious practices, views on gender, help-seeking, family values and personal success are different from more “individualistic” Western societies (Graham, Bradshaw, & Trew, 2010; Gunkel, Schlägel, & Engle, 2014). A good example of such a collectivist society is the Arabic culture (Graham et al., 2010). The TAS-20 has been validated in some Islamic countries like Iran (Besharat, 2007) and Turkey (Güleç et al., 2009), and higher scores on the measure have been linked to health problems like disordered eating (Celiken, Cumurcu, Koc, Etikan, & Yucel, 2008),
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mood disorders (Al-Eithan, Al Juban, & Robert, 2012) and schizophrenia (Heshmati, Jafari, Hoseinifar, & Ahmadi, 2010). To date, however, there have been no published studies to systematically assess the reliability and factorial validity of an Arabic version of the TAS-20 in a large predominantly Arabic-speaking sample. There are a number of reasons why this is a particularly important group for studying the generalizability of the alexithymia construct. Along with the need to further explore the potential generalizability of the alexithymia construct, health care providers in many regions are concerned about ongoing strategies for culturally competent care for the growing number of individuals of Arab backgrounds seeking mental health services in response to ongoing sociopolitical pressures (Amawi, Mollica, Lavelle, Osman, & Nasir, 2014; Amer & Claflin, 2013). Compared to individuals in other cultures, there are important differences in openness to help-seeking in Arab populations and how men and women in this cultural group interacts with treatment providers (Graham et al., 2010). Differential effects of gender and language/culture on a measure like the TAS-20 could shed light on how best to account for alexithymic traits when dealing with Arabic clients. This concern is also important in many western countries where recent immigrants of Arabic origin appear to be at elevated risk for experiencing mental health problems (Amer & Claflin, 2013; Padela & Heisler, 2010). The aim of the present study was to assess the reliability and factorial validity of an Arabic version of the TAS-20 in a large sample of young adults from three different Arabic-speaking regions: Algeria, Oman and Gaza. In an effort to demonstrate that the TAS-20 has generalizable psychometric properties and cultural sensitivity with the Arabic samples, we also collected data with a large sample of young adults from Canada.
Approximation (RMSEA). The cut-off scores for each index were as follows: GFI ≥ 0.85, AGFI ≥ 0.80, RMSR b 0.10 and RMSEA b 0.08 (Bentler, 1992; Cole, 1987). For RMSEA, we presented robust fit-indices (generated by EQS software). In a subsequent set of analyses we tested the measurement invariance of the 3-factor structure of the TAS-20 with respect to group within a multiple-group CFA framework by fitting the same model for the Arabic and Canadian samples simultaneously and imposing increasingly restrictive cross-group equality constraints on its parameters. We began with a baseline model with no equality constraints (configural invariance) and then conducted a test of invariant factor loadings (metric invariance) and a test of invariant factor covariances (structural invariance). Invariance was assumed to hold if these constrained models fit the data well and if there was minimal difference in their fit from that of the baseline model (Widaman & Reise, 1997). Because of the excessive Type I error rates associated with the chi-square difference test in large samples, we adapted a procedure recommended by Vandenberg and Lance (2000) and evaluated the relative fit of constrained models using change in GFI and AGFI, with minor differences of 0.015 or less indicating equivalent fit. In a final set of analyses we conducted a gender by group by subscale type (2 × 2 × 3) mixed MANOVA to assess the influence of gender and group variables and their interaction with the subscales on the TAS-20: difficulty identifying feeling (DIF), difficulty describing feelings (DDF) and externally-oriented thinking (EOT). This analysis utilized meanitem scores for the subscales given the unequal number of items (7 for DIF, 5 for DDF, and 8 for EOT).
2. Method
The three-factor structure of the TAS-20 showed good fit on the selected indices for both the Arabic (GFI = 0.95, AGFI = 0.93, RMSR = 0.06, RMSEA = 0.05) and Canadian samples (GFI = 0.95, AGFI = 0.94, RMSR = 0.05 and RMSEA = 0.04). Table 1 presents the item to factor standardized parameter estimates in both samples. All item-to-factor parameter estimates were significant (p b 0.05) with the exception of item 20 on EOT for the Arabic sample. Additionally, item 8 loaded negatively for factor 3 in the Arabic sample. The inter-factor parameter estimates were 0.773 (p b 0.05) and 0.910 (p b 0.05) between DIF and DDF, 0.106 (p b 0.05) and 0.100 (p b 0.05) between EOT, and DIF and 0.426 (p b 0.05) and − 0.030 (p N 0.05) between EOT and DDF for the Canadian and Arabic samples respectively. The only non-significant parameter estimate was between EOT and DDF in the Arabic sample. For the multiple-group CFAs, the configural invariance model Χ2 (328) = 2158.58 demonstrated good fit to the data (GFI = 0.950, AGFI = 0.938, SRMR = 0.054, RMSEA = 0.036 and 90% CI = [0.035, 0.037], indicating that the item composition of the three TAS-20 subscales was reasonably equivalent for both groups. The metric invariance model Χ2 (348) = 2845.10 was comparably well fitting (GFI = 0.937, AGFI = 0.924, SRMR = 0.069, RMSEA = 0.040 and 90% CI = [0.039, 0.042], indicating that the TAS-20 items did not function differentially for the two groups (change in GFI was − 0.013 and in AGFI was −0.014). The structural invariance model, Χ2 (352) = 2903.52 also fit the data comparably well (GFI = 0.935, AGFI = 0.923, SRMR = 0.071, RMSEA = 0.041 90% CI = [0.039, 0.042], indicating that there were limited group differences in either the nature of the latent dimensions or the degree of overlap among them (change in GFI was −0.015 and in AGFI was −0.015). Table 2 presents means and standard deviations for the TAS-20 variables by gender and group (Canadian vs Arabic). A MANOVA showed significant main effects for group F (1, 4417) = 1387.2, p b 0.05 and gender F (1, 4417) = 4.2, p b 0.05, with the Arabic sample scoring higher than the Canadian sample and men scoring higher than women. There was also a significant interaction for gender and group F (1, 4417) = 39.8, p b 0.05. Treating the type of subscale (alexithymia dimension)
2.1. Participants and procedure Participants in the study consisted of two groups. The first group was undergraduate students (n = 2221, 838 men and 1383 women) who completed an Arabic language version of the TAS-20 from three Arabic-speaking regions: Algeria (n = 655), Oman (n = 400) and Gaza (n = 1166). The second group were Canadian undergraduate students attending an Ontario university who completed the English language version of the instrument (n = 2200, 640 men and 1560 women). The mean age for the Arabic sample was 20.9 years (SD = 2.96); the mean age for the Canadian sample was 18.8 years (SD = 1.25). 2.2. Measures The TAS-20 is a multidimensional self-report instrument with 20 items rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The three factors include difficulty identifying feelings (DDF), difficulty describing feelings (DDF) and externally-oriented thinking (EOT). Higher scores on the scale resemble more severe alexithymia, with scores ranging from 20 to 100 and five reverse-scored items. The 20-item Toronto Alexithymia Scale (Bagby, Parker, & Taylor, 1994) was translated into Arabic and back-translated to English by a research team (Kafafi & Aldawash, 2011) fluent in both English and Arabic. Every effort was made to ensure that the translated version conveyed both literal and comprehensive meanings in Arabic. 2.3. Statistical analyses In the first set of analyses we used Confirmatory Factor Analysis (CFA) on both samples independently to assess the 3-factor structure of the TAS-20. CFA generates an array of goodness-of-fit indices to assess a model. We used the following array of fit indices: The Goodness-of-Fit Index (GFI), the Adjusted Goodness-of-Fit Index (AGFI), the Root Mean Square Residual (RMSR), and Root Mean Square Error of
3. Results
F.Z. El Abiddine et al. / Personality and Individual Differences 113 (2017) 219–222 Table 1 Standardized parameter estimates for CFA of the three-factor model: English [Arabic]. Item
DIF
Difficulty identifying feelings 1. I am often confused about… 3. I have physical sensations that… 6. When I am upset, I don't know if… 7. I am often puzzled by… 9. I have feelings that… 13. I don't know what's going on… 14. I often don't know why…
DDF
221
men on DIF (p b 0.001), DDF (p b 0.001), EOT (p b 0.001) and total TAS-20 (p b 0.001).
EOT
4. Discussion
0.70 [0.58] 0.30 [0.40] 0.65 [0.55] 0.13 [0.52] 0.76 [0.62] 0.71 [0.63] 0.49 [0.53]
Difficulty describing feelings 2. It is difficult for me to find…
0.76 [0.61] 0.69 [0.32] 0.58 [0.51] 0.49 [0.18] 0.57[0.33]
4 (R). I am able to describe… 11. I find it hard to describe… 12. People tell me to describe… 17. It is difficult for me to reveal… Externally-oriented thinking 5 (R). I prefer to analyze problems rather… 8. I prefer just to let things…
0.21 [0.45] 0.22 [−0.14] 0.69 [0.57] 0.49 [0.10] 0.17 [0.14]
10 (R). Being in touch with… 15. I prefer talking to… 16. I prefer to watch “light” entertainment… 18 (R). I can feel close to someone, even… 19 (R). I find examination of my feelings… 20. Looking for hidden meanings…
0.38 [0.34] 0.64 [0.63] 0.21 [0.03a]
Note: R = reversed worded item. a Non-significant loading.
as a repeated-measures variable revealed a significant main effect F (2, 8834) = 708.6, p b 0.05, interaction with group F (2, 8834) = 233.4, p b 0.05, and gender F (2, 8834) = 10.0, p b 0.05. The three-way interaction for subscale, gender and group was also significant F (2, 8834) = 7.2, p b 0.05. The Arabic sample scored higher on all three subscales compared to the Canadian sample, as well as significantly higher on total TAS-20 scores (t = 46.02, df = 4419, p b 0.05). Planned orthogonal comparisons showed that Arabic men scored significantly higher than Canadian men on DIF (p b 0.001), DDF (p b 0.05) and EOT (p b 0.001). Similarly, Arabic women scored significantly higher than Canadian women on DIF (p b 0.001), DDF (p b 0.001) and EOT (p b 0.001).Canadian men scored significantly higher than Canadian women on DDF (p b 0.001), EOT (p b 0.001)and total TAS-20 (p b 0.001), while Arabic women scored significantly higher than Arabic
Since the introduction of the scale over 2 decades ago the TAS-20 has been translated adequately into dozens of different languages (Taylor et al., 2003; Taylor et al., in press). The present study adds further support for the generalizability of the three-factor structure of the scale across diverse languages and cultures. More specifically, the present study suggests that the alexithymia construct can be generalized to collectivist societies, like Arabic countries, where the needs and goals of the group (family and community) are more emphasized over the needs and goals of the individual (Feghali, 1997; Hofstede, Hofstede, & Minkov, 2010). It is also important to note that Arabic culture strongly values actions that demonstrate self-worth and positive self-presentation, while at the same time placing considerable importance on selfreputation (Gregg, 2005). This latter feature of Arabic culture helps explain common reports in the health care literature that individuals from Arabic backgrounds are often reluctant to seek treatment for mental health problems (Amer & Claflin, 2013; Graham et al., 2010). Individuals in Arabic cultures, relative to other groups, often perceive self-disclosure to be a sign of personal weakness and thus a potential betrayal of their family and community (Sayed, 2002). This cultural difference may also explain the substantial mean differences in alexithymia scores that were found between the two groups. Both Arabic men and women scored significantly higher on the measure of alexithymia than Canadians, with the greatest discrepancy in women. It is worth noting that previous research using the TAS-20 with Islamic countries like Iran (Besharat, 2007) and Turkey (Güleç et al., 2009) reported overall alexithymia scores quite consistent with samples from Canadian and American samples. However, our results suggest that the high alexithymia scores in the Arabic sample may be the result of important cultural differences in the communication of emotional experiences. Another noteworthy point is that prior research has found somatization to be higher in Arabic speaking samples relative to other groups (Alqahtani & Salmon, 2008; Racy, 1980). This cultural difference has been suggested to reflect greater social stigma being attached to mental illness, as “somatization may conceal emotional distress by emphasizing a sick role that is socially acceptable in the culture” (Becker, 2004, p. 964). Although the overall three-factor structure of the TAS-20 items showed good fit for the Arabic sample, there were several limitations in the results that need to be noted. Item to factor parameter estimates for a number of items on the Externally Oriented Thinking (EOT) factor were nonsignificant or quite low relative to loadings for other factors. This pattern of results for the EOT factor has been reported with other cultural groups (Taylor et al., 2003). It is worth noting that Besharat (2007), using a Farsi translation of the TAS-20, and Güleç et al. (2009) using a Turkish translation, found problems with several of the EOT items problematic in the present study. Cultural differences in the
Table 2 Means and standard deviations of all TAS-20 variables by group and gender. Group
Gender
N
DIF
DDF
EOT
Total
Combined Arab Canadian Combined Combined Arab Arab Canadian Canadian
Combined Combined Combined Men Women Men Women Men women
4421 2221 2.220 1478 2943 838 1383 640 1560
2.45 (0.84) 2.71 (0.80) 2.06 (0.65) 2.43 (0.80) 2.46 (0.85) 2.71 (0.80) 2.90 (0.84) 2.06 (0.64) 2.07 (0.65)
2.63 (0.78) 2.70 (0.69) 2.46 (0.81) 2.64 (0.75) 2.63 (0.79) 2.69 (0.69) 2.86 (0.71) 2.57 (0.80) 2.42 (0.81)
2.92 (0.67) 3.28 (0.55) 2.51 (0.53) 2.97 (0.66) 2.89 (0.67) 3.28 (0.55) 3.33 (0.53) 2.56 (0.56) 2.49 (0.52)
53.63 (11.81) 60.32 (10.02) 46.87 (9.39) 53.96 (11.13) 53.46 (12.14) 58.72 (9.85) 61.29 (10.01) 47.73 (9.51) 46.52 (9.32)
Note: DIF = difficulty identifying feelings, DDF = difficulty describing feelings; EOT = externally-oriented thinking. Mean-item scores are reported for DIF, DDF, and EOT.
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meanings given to a number of these items might be partly responsible for the low parameter values. 4.1. Limitations and future directions The results should be replicated in further research with the TAS-20 in Arabic speaking samples, especially because the present sample was restricted in age to young adults attending a post-secondary institution. The psychometric properties of the Arabic TAS-20 and its factor structure in different clinical and nonclinical populations, as well as in older and less educated Arabic adults have still to be explored. It is also important to note that Arab culture is itself quite diverse; future research needs to clarify that the alexithymia construct can be generalizable to different Arabic speaking subgroups (Amer & Claflin, 2013). It is also not clear from the current study what the overall health implications might be in Arabic speaking populations for high levels of alexithymia. While high levels of alexithymia have been linked with a cross-section of negative health outcomes in Western cultures (Taylor et al., 1997), this pattern does not generalize to all cultural groups. For example, there is an interesting body of work suggesting that for East Asian collectivist cultures the mental health impact of a related construct like emotional suppression is far more positive than for western individualistic cultures (Mauss & Butler, 2010; Soto, Perez, Kim, Lee, & Minnick, 2011). Future research needs to systematically explore the impact of alexithymia on various mental and physical variables in Arabic speaking populations. References Al-Eithan, M. H., Al Juban, H. A., & Robert, A. A. (2012). Alexithymia among Arab mothers of disabled children and its correlation with mood disorders. Saudi Medical Journal, 33(9), 995–1000. Alqahtani, M. M., & Salmon, P. (2008). Prevalence of somatization and minor psychiatric morbidity in primary healthcare in Saudi Arabia: A preliminary study in Asir region. Journal of Family and Community Medicine, 15, 27–33. Amawi, P. N., Mollica, R. F., Lavelle, J., Osman, O., & Nasir, L. (2014). Overview of research on the mental health impact of violence in the Middle East in light of the Arab spring. Journal of Nervous and Mental Disease, 202, 625–629. Amer, M. M., & Claflin, A. B. (2013). Psychological research with Muslim Americans in the age of islamophobia: Trends, challenges, and recommendations. American Psychologist, 68(3), 134–144. Bagby, R. M., Parker, J. D. A., & Taylor, G. J. (1994). The Twenty-item Toronto Alexithymia Scale I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research, 38, 23–32. Bentler, P. M. (1992). On the fit of models to covariances and methodology to the Bulletin. Psychological Bulletin, 112, 400–404. Besharat, M. A. (2007). Reliability and factorial validity of a Farsi version of the 20-Item Toronto Alexithymia Scale with a sample of Iranian students. Psychological Reports, 101(1), 209–220. Celiken, F. C., Cumurcu, B. E., Koc, M., Etikan, I., & Yucel, B. (2008). Psychologic correlates of eating attitudes in Turkish female college students. Comprehensive Psychiatry, 49, 188–194. Cole, D. A. (1987). Utility of confirmatory factor analysis in test validation research. Journal of Consulting and Clinical Psychology, 55, 584–594.
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