2 The body as a (muffled) sound box for emotion 57 the TAS-20, as it contains 5 subscales and also distinguishes between cognitive and affective alexithymia. The five subscales are: 1) Inability to emotionalize (the ease with which one becomes mentally emotionally aroused by internal or external stimuli); 2) Inability to fantasize; 3) Inability to identify emotions; 4) Inability to analyze emotions; and 5) Inability to verbalize emotions. The first two subscales together measure affective alexithymia, the latter three measure cognitive alexithymia. The BVAQ-40, like the TAS-20, is available in multiple languages, is wellvalidated for use in multiple populations and was found to have sound psychometric qualities. The distinction between cognitive and affective alexithymia can be appealing to clinicians who like to determine fine-grained diagnoses. With two forms of alexithymia either present or absent, one can distinguish (at least) four subtypes of alexithymia [48, 104, 105]. For example, one subtype could be a patient who is emotionally arousable (and who can also report this), yet cannot really identify, analyze, and verbalize what he is feeling. Another subtype could be a patient who can hardly be aroused emotionally, but who can still distinguish well between emotions and can even elaborate on them, yet without really feeling them. In the former case, the patient is capable of affective experiences, but due to ‘cognitive alexithymia’ lacks the capacity to rationally process them. In the latter, the verbal (or cognitive) abilities would be present, but the emotional experience is lacking due to ‘affective alexithymia’. Still, empirical evidence for the existence of subtypes remains scarce. In fact, the use of clear-cut categories or subtypes is also in contrast with recent developments towards a spectrum-based model based upon insights in neurobiological and psychological working mechanisms [59, 76, 106]. Observer Alexithymia Scale (OAS) In addition to self-reporting instruments, there are various observer rating scales to measure alexithymia. One of these is the Observer Alexithymia Scale (OAS) [107]. An advantage of an observer rated instrument such as the OAS is that it can be completed by hopefully a more objective third party. In terms of validity, this is a strong argument for its use, given the limitations of self-reporting. Compared to other observer scales, the OAS has the additional advantage that it does not require formal training to use it. The psychometric qualities of the OAS are overall acceptable. However, reliability of some subscales is questionable [108]. A translation is available for Dutch-speaking populations. Beth Israel Hospital Psychosomatic Questionnaire (BIQ) and Toronto Structured Interview for Alexithymia (TSIA) A third type of diagnostic instrument for assessing alexithymia is the structured interview. Most of the interview instruments that were developed were either a
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