Relationships between alexithymia, metacognitive beliefs, and severity of psychotic symptoms in schizophrenia patients

Introduction Alexithymia is a multidimensional clinical feature characterized by difficulty in recognizing, naming, and expressing emotions. The Toronto Alexithymia Scale-20(TAS-20) is used for assessing alexithymia and includes dimensions of difficulty in recognizing and expressing emotions, and externalized thinking(1). A recent study reported a prevalence of alexithymia in schizophrenia of 35%(2). Metacognitive beliefs are an individual’s beliefs and evaluations about their own thoughts; the MCQ-30 is a short scale developed to assess this area(3). This study investigated the relationships between alexithymia, metacognitive beliefs, and psychotic symptom severity assessed by the PANSS in schizophrenia patients. The PANSS is a standard clinical scale developed to assess positive, negative, and general psychopathology symptoms in schizophrenia(4).

Methods The cross-sectional study included 85 schizophrenia patients with sufficient PANSS data. Alexithymia was assessed using the TAS-20 total score, metacognitive beliefs using the MCQ-30 total score, and psychotic symptom severity using PANSS positive, negative, general psychopathology, and total scores. Since low internal consistency was observed in the TAS subscales, particularly the externalizing thinking subscale, analyses were conducted solely on the TAS-20 total score. In the main analysis, the TAS-20 total score, MCQ-30 total score, PANSS subscales, age, age of onset, and total number of hospitalizations were used to predict outcomes. The indirect pathway model PANSS total→ MCQ-30 total→TAS-20 total was tested with a 5000 bootstrap sample.

Results

The main path model explained 23.7% of the variance in the total TAS-20 score. When PANSS symptom domains and clinical-demographic covariates were controlled for, the MCQ-30 total score significantly predicted the TAS-20 total score. The PANSS negative symptom score was positively correlated with the total TAS-20 score. The PANSS positive symptom score, age, age of onset, and total number of hospitalizations were not significant predictors. The negativity of the PANSS general psychopathology coefficient was considered a possible suppressive effect due to the high overlap between PANSS negative and general psychopathology domains. In the indirect path analysis, the total PANSS score did not significantly predict the total MCQ-30 score, B=0.113, β=.135, p=.272. The total MCQ-30 score significantly predicted the total TAS-20 score, B=0.228, β=.316, p=.004. However, the indirect effect of PANSS total → MCQ-30 total → TAS-20 total was not significant, B=0.026, β=.043, 95% CI [−0.019, 0.083], p=.301. There was no statistically significant support for the association between metacognitive beliefs and alexithymia with general psychotic symptom burden.

Discussion and Conclusion

The findings suggest that alexithymia in schizophrenic patients cannot be explained solely by the overall severity of psychotic symptoms; metacognitive beliefs may have an independent relationship with alexithymia. In particular, negative symptoms and dysfunctional metacognitive beliefs appear to be more closely related to the level of alexithymia. In contrast, the indirect pathway model established through the total PANSS score was not supported. This result suggests that the relationship between alexithymia and metacognitive beliefs may be a clinical link independent of the overall psychotic symptom burden. Due to the cross-sectional design, causal interpretations should not be made. The findings should be tested with larger sample sizes, longitudinal designs, and models where the sub-dimensions of the scale are evaluated more psychometrically.

References

Reference

1. 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(1), 23–32. https://doi.org/10.1016/0022-3999(94)90005-1 Reference
2. Xiao, Y., Tian, J., Pan, Y. F., Dai, Y., Sun, Y. J., Zhou, Y., & Xiang, Y. T. (2024). The prevalence of alexithymia in schizophrenia: A systematic review and meta-analysis. Asian Journal of Psychiatry, 102, 104280. https://doi.org/10.1016/j.ajp.2024.104280 Reference
3. Wells, A., & Cartwright-Hatton, S. (2004). A short form of the Metacognitions Questionnaire: Properties of the MCQ-30. Behaviour Research and Therapy, 42(4), 385–396. https://doi.org/10.1016/S0005-7967(03)00147-5 Reference
4. Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale for schizophrenia. Schizophrenia Bulletin, 13(2), 261–276. https://doi.org/10.1093/schbul/13.2.261