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Alexithymia and emotional empathy following

traumatic brain injury
a a
Claire Williams & Rodger Ll. Wood
a
Brain Injury Research Group, Department of Psychology , School of Human
Sciences, Swansea University , Swansea, UK
Published online: 22 Jun 2009.

To cite this article: Claire Williams & Rodger Ll. Wood (2010) Alexithymia and emotional empathy
following traumatic brain injury, Journal of Clinical and Experimental Neuropsychology, 32:3, 259-267, DOI:
10.1080/13803390902976940

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 JOURNAL OF CLINICAL AND EXPERIMENTAL NEUROPSYCHOLOGY
2010, 32 (3), 259–267

Alexithymia and emotional empathy following

NCEN

traumatic brain injury

Claire Williams and Rodger Ll. Wood

Alexithymia and Emotional Empathy Following TBI

Brain Injury Research Group, Department of Psychology, School of Human Sciences, Swansea
University, Swansea, UK

The frequency of alexithymia and the proportion of cases reporting low emotional empathy after traumatic brain
injury (TBI) were compared with a control group. The study also examined the relationship between alexithymia
and emotional empathy, controlling for the influence of cognitive ability, severity of head injury, and time since
Downloaded by [Stony Brook University] at 19:44 21 October 2014

injury. A total of 64 TBI patients and matched controls completed the 20-Item Toronto Alexithymia Scale
(TAS-20) and Balanced Emotional Empathy Scale (BEES). The TBI group exhibited a significantly higher fre-
quency of alexithymia (60.9%) and low emotional empathy (64.4%) than did the control group (10.9% and
34.4%). Significant moderate negative correlations were found between TAS-20 and BEES scores, with TAS-20
total scores accounting for a significant amount of variance in BEES scores. However, no significant correlation
was obtained between Subscale 1 of the TAS-20 (difficulty identifying feelings) and BEES scores in the TBI group.
Additionally, there were no significant relationships between alexithymia, emotional empathy, injury severity, and
time since injury. The results suggest an inverse relationship between alexithymia and emotional empathy.

Keywords: 20-Item Toronto Alexithymia Scale; Balanced Emotional Empathy Scale; Traumatic brain injury;
Emotional perception; Emotion recognition; Injury severity.

Alexithymia is a multifaceted construct comprising: (a)
difficulty identifying and describing emotions; (b) a
concrete communication style; (c) an externally ori-
ented style of thinking, and (d) limited imaginal capa-
city (Taylor, Bagby, & Parker, 1997). Alexithymia has
been associated with dysfunction in a number of cere-
bral structures, including the right hemisphere (Mandal
et al., 1999), the corpus callosum (Houtveen, Bermond,
& Elton, 1997), and the frontal lobes (Berthoz et al.,
2002; Hornak, Rolls, & Wade, 1996). Consequently,
alexithymia should be prevalent following head trauma
because of the predominant involvement of frontal
structures in such injuries (Adams, Graham, Murray, &
Scott, 1982). This has been confirmed in a number of
studies (Allerdings & Alfano, 2001; Becerra, Amos, &
Jongenelis, 2002; Henry, Phillips, Crawford,
Theodorou, & Summers, 2006; Koponen et al., 2005;
Williams et al., 2001; Wood & Williams 2007), using
the 20-item Toronto Alexithymia Scale (TAS-20;
Bagby, Parker, & Taylor, 1994a; Bagby, Taylor, &
Parker, 1994b).
The difficulty experienced by those with alexithymia
when describing their own emotional state often extends
to difficulty interpreting the emotional states of others
(Bagby, Parker, Taylor, & Acklin, 1993), particularly
when emotion has to be interpreted from facial expres-
sions (Lane et al., 1996). Therefore, the presence of alex-
ithymia may explain not only why many patients with
traumatic brain injury (TBI) exhibit deficits in process-
ing and expressing emotions, as referenced above, but
also why many lack the ability to understand another
person’s feelings—a loss of empathy (Preston & de
Waal, 2002; Wood & Williams, 2008). As a construct,
empathy can be divided into emotional and cognitive
components that draw upon separate, but overlapping,
neurological systems (Decety & Jackson, 2004;
Heberlein & Saxe, 2005; Preston & de Waal, 2002;
Shamay-Tsoory et al., 2007). Emotional empathy refers

The information in this manuscript and the manuscript itself are new and original, are not currently under review by any other
publication, and have never been published either electronically or in print. The authors have no financial relationships or conflict of
interest to disclose. Funding for this research was obtained, in part, from the Brain Injury Rehabilitation Trust, UK.
Address correspondence to Claire Williams, Department of Psychology, School of Human Sciences, Swansea University, Singleton
Park, Swansea, SA2 8PP, UK (E-mail: 200528@swansea.ac.uk).

© 2009 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
http://www.psypress.com/jcen DOI: 10.1080/13803390902976940
 260 WILLIAMS AND WOOD
to the ability to vicariously experience the emotions of
others (Mehrabian, 2000) and has been associated with
the insula and inferior frontal gyrus (Schulte-Ruther,
Markowitsch, Fink, & Piefke, 2007; Shamay-Tsoory
et al., 2007; Singer et al., 2004), whereas cognitive empa-
thy, the capacity to comprehend another’s situation in a
way that allows mutual sharing and understanding
(Hogan, 1969), has been linked to the ventromedial pre-
frontal cortex (Shamay-Tsoory et al., 2007). These struc-
tures are vulnerable to mechanisms of TBI, and
therefore, similar to alexithymia, cognitive and emo-
tional aspects of empathy are likely to be compromised
(Shamay-Tsoory et al., 2007).
The limited research on empathy following head
trauma has, until very recently, only examined cognitive
empathy. Grattan and Eslinger (1989), in a study con-
taining 40 stroke and 10 TBI cases, found that 58% of
patients reported low cognitive empathy. Similarly,
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Wells, Dywan, and Dumas (2005) reported a lack of cog-
nitive empathy following TBI, which adversely affected
ratings of life satisfaction. Wood and Williams (2008)
took a different approach and examined the impact of
TBI on emotional empathy, measured by the Balanced
Emotional Empathy Scale (BEES; Mehrabian, 2000) in
a TBI sample (N = 89). They found a high frequency
(60.7%) of low emotional empathy in the TBI group
compared to a control group (31%) matched for age,
gender, intelligence, and socioeconomic status.
Early clinical (Krystal, 1979; McDougall, 1989; Tay-
lor, 1987) and research evidence has confirmed an
inverse relationship between alexithymia and empathy in
clinical and nonclinical populations (Guttman &
Laporte, 2002; Parker, Taylor, & Bagby, 2001; Rastam,
Gillberg, Gillberg, & Johansson, 1997). In a sample of
college students, Moriguchi et al. (2007) found that an
alexithymia group reported low scores on an emotional
empathy scale. Similarly, Davies, Stankov, and Roberts
(1998), in a community sample of adults, reported a sig-
nificant negative correlation between emotional empa-
thy and the “externally oriented thinking” subscale of
the TAS-20. These studies imply that the presence of
alexithymia may render the individual unable to vicari-
ously experience the emotions of others. This has major
implications for understanding the emotional problems
exhibited by many people who have suffered TBI, often
leading to relationship failure (Wood, Liossi & Wood,
2005; Wood & Yurdakul, 1997). However, to the
authors’ knowledge, there has been no attempt to exam-
ine the relationship between alexithymia and emotional
empathy in patients who have suffered TBI.
The present study therefore aimed to confirm the pres-
ence of alexithymia and low emotional empathy follow-
ing TBI and also to examine the relationship between
alexithymia and emotional empathy in a TBI and con-
trol group, on the assumption that if one cannot identify
or describe one’s own emotions (alexithymia), then the
ability to recognize and experience emotions in others
(emotional empathy) should also be impaired. Cognitive
ability may be an important factor mediating this rela-
tionship because recent studies have found a relationship
between alexithymia, verbal ability, and working
memory, and between empathy and cognitive flexibility
(Grattan, Bloomer, Archambault, & Eslinger, 1994;
Henry et al., 2006; Shamay-Tsoory, Tomer, Berger, &
Aharon-Peretz, 2004; Wood & Williams, 2007, 2008).
Therefore, a further aim of the study was to examine the
relationship between alexithymia and emotional empa-
thy, whilst controlling for the influence of cognitive abil-
ity. The final aim was to examine the relationship
between alexithymia, emotional empathy, injury sever-
ity, and time since injury.
On the basis of existing literature, several hypotheses
were proposed. First, consistent with previous research
(Wood & Williams, 2007, 2008), it was hypothesized that
the frequency of alexithymia in a TBI group and the pro-
portion of TBI cases reporting reduced emotional empa-
thy would exceed those in a healthy control group
matched according to gender, age, years of education,
employment status, and marital status. Second, it was
anticipated that an inverse relationship would exist
between alexithymia and emotional empathy (Davies et
al., 1998; Guttman & Laporte, 2002; Moriguchi et al.,
2007) and that this relationship would persist when con-
trolling for the influence of cognitive ability. Third, con-
sistent with previous research examining the emotional
consequences of head trauma (Wood & Williams, 2007,
2008), there would be no evidence of a relationship
between alexithymia, emotional empathy, injury sever-
ity, or time since injury.
METHOD
Participants
TBI group
All TBI cases had been referred to the University
Brain Injury Clinic during 2007–2008 for advice on the
management of long-term neuropsychological sequelae.
During this period 90 TBI cases were referred. Patients
were excluded if the impression at clinical interview (con-
ducted by R.L.W.), or performance on neuropsychologi-
cal tests, threw doubt on the capacity of patients to
provide informed consent to participate in the study.
Other exclusion criteria for the patient group (and the
control group) comprised a preaccident history of psy-
chiatric and/or personality disorder, a history of previ-
ous head trauma or neurological disorder, a
developmental history of learning disability, an esti-
mated preaccident IQ < 70, (which could affect ability to
recognize and express emotion), or dysphasia or any
other language or neurological disorder that would com-
promise ability to complete the measures. Participants
below the age of 20 years at assessment were excluded
because they could be considered socially immature (in
respect of the role of the frontal lobes in social matura-
tion), which may influence responses on emotion mea-
sures (Wood & Williams, 2007, 2008).
A total of 64 patients with TBI (71.1%) who had not
previously participated in any research study (e.g., Wood
& Williams, 2007, 2008), met these criteria. A total of 64
control participants were recruited from friends and
 ALEXITHYMIA AND EMOTIONAL EMPATHY FOLLOWING TBI
family and from academic departments across Swansea
University. The mean time between injury and assess-
ment was 3.19 years (SD = 2.58 years; range 0.63–16.27
years). Injury severity was determined by the length of
posttraumatic amnesia (PTA; McMillan, Jongen, &
Greenwood, 1996; Russell & Smith, 1961; mean: 16.85
days; SD = 27.84, range 1–210) and Glasgow Coma Scale
(GCS; Teasdale & Jennett, 1974) scores at the time of
hospital admission (mean: 9.30; SD = 4.46, range 3–15).
All TBI patients were required to have a PTA or GCS
score indicative of moderate to severe TBI (PTA > 24
hours, GCS < 12). Mean age at injury was 32.77 years
(SD = 13.32, range 15–62) and at assessment was 35.84
years (SD = 13.33, range 20–62). The cohort had an aver-
age of 12.14 years of education (SD = 2.18, range 8–20).
Prior to injury, 75% (N = 48) of the cohort were
employed on a full-time or part-time basis, 10.9% (N = 7)
were in education, and 14.1% (N = 9) were unemployed.
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At the time of assessment, 35.9% (N = 23) remained in
full- or part-time employment, 3.1% (N = 2) were in edu-
cation, 1.6% (N = 1) were retired, and 59.4% (N = 38)
were either unemployed or working as volunteers.
Control group
This consisted of 64 participants, of whom 53 (82.8%)
were male. The mean age of participants at assessment
was 36.09 years (SD = 14.24, range 20–62). The control
group had an average of 12.98 years of education (SD =
2.775, range 10–20). At the time of assessment 53.1% (N
= 34) of the cohort were employed on a full-time or part-
time basis, 4.7% (N = 3) were in education, 4.7% (N = 3)
were retired, and 37.5% (N = 24) were unemployed. None
of the control cohort had a formal history of neurological
disorder, psychiatric illness, or any kind of preinjury per-
sonality disorder that could be interpreted as evidence of
a reduced ability to regulate aspects of emotion.
The TBI and control group, comprising the same
number of males and females, (male N = 53, female N =
11) were compared on standard demographic informa-
tion. The two groups did not differ on age at assessment
(U = 2,030.00, Z = –0.086, p > .05), years of education
(U = 1,582.00, Z = −2.321, p > .05), employment status
(preaccident employment status), c2(3) = 9.363, p > .05,
or marital status (preaccident marital status), c2(3) =
6.772, p > .05.
Measures
The presence of alexithymia was determined using the
20-item Toronto Alexithymia Scale (TAS-20; Bagby
et al., 1994a, 1994b), composed of 20 items that partici-
pants endorse on a 5-point Likert-type scale, ranging
from “strongly disagree” to “strongly agree.” The TAS-
20 total score can range from 20–100. A score ≥61 con-
firms alexithymia; 51–60 indicates “possible” alex-
ithymia; ≤51 indicates an absence of alexithymia (Bagby
et al., 1994a, 1994b). In addition to the TAS-20 total
score, the TAS-20 consists of three subscales: difficulty
identifying feelings (Subscale 1), difficulty describing
261
feelings (Subscale 2), and externally oriented thinking
(Subscale 3; Bagby et al., 1994a; Parker, Taylor, Bagby,
Endler, & Schmitz, 1993; Taylor et al., 1997). The TAS-
20 has demonstrated convergent and discriminant valid-
ity, and scores show high agreement with observer
ratings of alexithymia (Bagby et al., 1994a, 1994b). The
TAS-20 has been used extensively in both clinical and
nonclinical populations (Burba et al., 2006; Koponen
et al., 2005; Luminet, Bagby, & Taylor, 2001; Wood &
Williams, 2007; Parker et al., 2001; Parker et al., 1993).
The Balanced Emotional Empathy Scale (BEES;
Mehrabian, 2000) was employed as a measure of emo-
tional empathy. The BEES is designed to distinguish per-
sons who experience more of the feelings of others from
those who are generally less responsive to the emotional
expressions and experiences of others. It contains 30
items (15 positive and 15 negatively worded questions)
that participants endorse on a 9-point Likert-type scale,
ranging from very strong agreement to very strong disa-
greement. A total score is computed for each participant
by summing responses to all 15 of the positively worded
items and by subtracting from this the sum of responses
to all 15 of the negatively worded items. Total scores are
then transformed into z scores, with a z score of ≤–1.0
indicating low emotional empathy, –0.5 to 1.0 average
emotional empathy, and ≥1.0 high emotional empathy.
Internal consistency of the BEES has been reported as .87
(Mehrabian, 1997b), and validity data for the BEES were
reported by Mehrabian (1997a). The BEES has been used
with a number of clinical populations (Danziger,
Prkachin, & Willer, 2006; Eslinger, Parkinson, &
Shamay, 2002), including TBI (Wood & Williams, 2008).
Tests of cognitive ability from the Wechsler Adult
Intelligence Scale–Third Edition (WAIS–III; Wechsler,
1997a) were administered to the TBI participants as part
of a routine clinical assessment. The tests varied slightly
in number and combination based on clinical circum-
stances at the time of assessment. For the purpose of this
study, subtests were grouped into domains according to
whether they comprised tests of verbal ability, tests of
working memory, or tests that, in the author’s opinion,
involved a degree of cognitive flexibility.
Verbal ability:
Vocabulary, Similarities, Comprehension.
Working memory:
Digit Span, Letter–Number Sequencing, Spatial
Span.
Cognitive flexibility:
Block Design, Matrix Reasoning, Picture
Arrangement.
These groupings have been employed in previous studies
(Wood & Rutterford, 2006a, 2006b; Wood & Williams,
2007, 2008). Each subtest has good reliability and valid-
ity in clinical populations (WAIS–III, Tulsky, Zhu, &
Ledbetter, 1997; Wechsler Memory Scale–Third Edition,
WMS III, Wechsler, 1997b) and was chosen to represent
abilities that may mediate relationships between
alexithymia and emotional empathy. Previous research
has reported a negative relationship between verbal
 262 WILLIAMS AND WOOD
ability and alexithymia (Lamberty & Holt, 1995; Wood
& Williams, 2007), suggesting that poor verbal ability
may result in a limited capacity to verbalize, and respond
meaningfully to, emotional experiences. A negative rela-
tionship between working-memory tasks and alex-
ithymia has also been reported (Henry et al., 2006;
Wood & Williams, 2007). The working-memory tests
included in this study involve sequencing of information,
which helps participants keep track of emotional experi-
ence and put such experience into context. Tests of cog-
nitive flexibility help determine whether emotional
processing interacts with higher level cognitions involved
in social awareness and judgment, although findings on
this topic are mixed (Grattan et al., 1994; Shamay-
Tsoory et al., 2004; Wood & Williams, 2008).
Procedure
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Ethical approval for the study was obtained from the
Department of Psychology, School of Human Sciences,
Swansea University, and the South West Wales National
Health Service (NHS) Local Research and Ethics
Committee.
Patients were administered the above neuropsychologi-
cal tests by the second author as part of a routine clinical
neuropsychological examination. Upon completion they
completed the TAS-20 and BEES. Demographic details
and information relating to head trauma were obtained
from practitioner records and hospital case notes. Control
participants were administered the TAS-20 and BEES and
were asked to provide information on a number of demo-
graphic details, including gender, date of birth, years of
education, current employment status, and marital status.
Statistical analysis
Preliminary analyses examined the presence of outliers
and the assumptions of normality, linearity, and homo-
scedasticity, and unless stated otherwise, parametric ana-
lysis was performed on the data set. A test of proportion,
to examine the significance of the difference between two
independent samples, was conducted on the TAS-20 and
BEES to investigate the frequency of individuals with
alexithymia and low emotional empathy in the TBI group,
compared to the matched control group. Pearson correla-
tion, linear regression, and hierarchical multiple regres-
sion techniques were conducted to investigate the
relationship between alexithymia and emotional empathy.
Spearman correlation, independent t tests, and a one-way
analysis of variance (ANOVA) examined the relationship
between the TAS-20, BEES, and injury severity.
RESULTS
Frequency of alexithymia
TBI and control group
The TBI and control group were divided into three
groups based on their TAS-20 scores. The TBI group
recorded a significantly higher frequency of alexithymia
(alexithymia: 60.9%; possible alexithymia: 20.3%; no
alexithymia: 18.8%) than did the control group (alex-
ithymia: 10.9%; possible alexithymia: 17.2%: no alex-
ithymia: 71.9%). The proportion of .609 (39 out of 64)
individuals with alexithymia in the TBI group was signif-
icantly different from the control group proportion of
.109 (7 out of 64; Z = 5.895, <.0001).
The TBI group reported significantly higher mean
scores for the TAS-20 total score and all three subscale
scores (Table 1): TAS-20 total score, t(126) = 8.642, p <
.0005, h2 = .37; SubScale Score 1, t(126) = 8.398, p < .0005,
h2 = .35; SubScale Score 2, t(126) = 6.311, p < .0005, h2 =
.24; SubScale Score 3, t(126) = 4.744, p < .0005, h2 = .15.
Frequency of low emotional empathy
TBI and control group
The TBI and control groups were divided into three
groups based on their BEES scores. The TBI group
recorded a significantly higher frequency of low emo-
tional empathy (low emotional empathy: 64.1%; average
emotional empathy: 28.1%; high emotional empathy:
7.8%) than the control group (low emotional empathy:
34.4%; average emotional empathy: 53.1%; high emo-
tional empathy: 12.5%). The proportion of the TBI group
with low emotional empathy, .640 (41 out of 64, male N
= 38, female N = 3), is significantly different from the
control group proportion of .343 (22 out of 64, male N =
21, female N = 1; Z = 3.359, p < .001). The TBI group
recorded significantly lower BEES scores than the con-
trol group, t(126) = –3.348, p < .001, h2 = .08 (Table 1).
Relationship between alexithymia and emotional
empathy
TBI group
Cognitive ability may be an important factor mediat-
ing the relationship between TAS-20 and BEES scores.
To investigate this further, hierarchical multiple regres-
sion analysis was performed. Each measure from the ver-
bal ability (vocabulary, similarities, comprehension),
working memory (digit span, letter number sequencing,
spatial span), and cognitive flexibility (block design,
matrix reasoning, picture arrangement) domains were
entered in Steps 1, 2, and 3 of the regression, and TAS-
20 scores were entered in Step 4 (see Table 1 for descrip-
tives). Table 2 shows that verbal ability alone (Step 1)
did not explain a significant amount of variance in BEES
scores, F(3, 54) = 1.398, p > .05. However, the introduc-
tion of working memory in Step 2 resulted in a signific-
ant change to the amount of variance explained, but the
overall model was not significant, F(6, 51) = 2.261, p >
.05. Similarly, the introduction of flexibility measures
(Step 3) did not produce a significant change, F(9, 48) =
1.867, p > .05. When TAS-20 scores were introduced
(Step 4) the regression produced a significant change in
the amount of variance explained, and the overall model
was significant, F(10, 47) = 2.584, p < .005. Therefore,
 ALEXITHYMIA AND EMOTIONAL EMPATHY FOLLOWING TBI 263

TABLE 1
Mean and standard deviations for alexithymia, emotional empathy, and cognitive measures

TBI (N = 64) Control (N = 64)

Measure N Mean SD Mean SD

Alexithymia
TAS-20 SubScale 1 (difficulty identifying feelings) 64 22.09 6.59 12.88 5.79
TAS-20 SubScale 2 (externally orientated thinking) 64 17.09 4.24 12.28 4.38
TAS-2- SubScale 3 (difficulty describing feelings) 64 22.70 4.98 18.69 4.58
TAS-20 Total score 64 62.33 12.09 43.92 11.99
Emotional empathy
BEES Total score 64 15.08 24.33 33.28 26.69
WAIS–III scale scores
Vocabulary 64 8.36 2.10
Similarities 64 8.05 1.79
Comprehension 62 8.11 2.45
Digit Span 63 9.14 2.96
Letter–Number Sequencing 63 8.68 2.97
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Spatial Span 64 9.47 3.07

Block Design 63 9.63 2.57
Matrix Reasoning 61 10.21 2.92
Picture Arrangement 64 8.86 1.51

Note. TBI = traumatic brain injury. TAS-20 = 20-item Toronto Alexithymia Scale. BEES = Balanced Emotional
Empathy Scale. WAIS–III = Wechsler Adult Intelligence Scale–Third Edition.

TABLE 2
Hierarchical regression analysis

Adjusted R2 F F
2
R R R2 change change change sig. B SE b value t value

Step 1 .268 .072 .021 .072 1.398 .253

Vocabulary −6.378 3.581 −.412 −1.781
Similarities −0.782 3.299 −.043 −0.237
Comprehension 4.290 2.912 .322 1.473
Step 2 .458 .210 .117 .138 2.972 .040*
Digit Span 4.464 2.247 .407 1.987
Letter Number Sequencing 2.017 1.927 .186 1.047
Spatial Span −1.657 1.791 −.158 −0.925
Step 3 .509 .259 .120 .049 1.062 .374
Block Design 3.868 2.432 .304 1.591
Matrix Reasoning −2.776 2.440 −.246 −1.138
Picture Arrangement 0.347 3.326 .015 0.104
Step 4 .596 .355 .217 .095 6.951 .011**
TAS-20 total scores −1.037 0.393 −.378 −2.637**

Note. TBI = traumatic brain injury. TAS-20 = 20-item Toronto Alexithymia Scale.
*p < .05. **p < .005.

TAS-20 scores were able to explain a significant amount
of variance in BEES scores, even when controlling for
variance explained by cognitive ability.
In the TBI group, 71.8% of alexithymia cases, 53.8%
possible alexithymia, and 50% no alexithymia reported
low emotional empathy scores on the BEES. Pearson cor-
relations found a significant, moderate negative correla-
tion between TAS-20 total and BEES scores. High levels
of alexithymia were associated with low levels of emo-
tional empathy (r = –.323, N = 64, p < .005). Pearson cor-
relation analysis also revealed significant (moderate)
negative correlations between Subscales 2 and 3 of the
TAS-20 and BEES (Subscale 2 and BEES: r = –.401, N =
64, p < .001; Subscale 3 and BEES: r = –.233, N = 64, p <
.05). A negative correlation was obtained between Sub-
scale 1 of the TAS-20 and BEES but this was not signific-
ant (Subscale 1 and BEES: r = –.122, N = 64, p > .05). A
linear regression analysis was performed to determine
how much variance in BEES scores could be explained by
TAS-20 total scores. The analysis revealed that TAS-20
scores explained 9% of the variance in BEES scores,
adjusted R2 = .09, F(1, 63) = 7.206, p < .01.
 264 WILLIAMS AND WOOD
Control group
In the control group, 57.1% of cases in the “alex-
ithymia group,” 36.4% in the “possible alexithymia,”
and 30.4% in the “no alexithymia” group, reported low
emotional empathy scores on the BEES. Analysis
revealed a significant moderate negative correlation
between the TAS-20 total score and the BEES (r = –.473,
N = 64, p < .0001). Furthermore, significant (moderate
to strong) negative correlations were obtained between
each of the TAS-20 subscale scores and the BEES (Sub-
scale 1: r = –.313, N = 64, p < .01; Subscale 2: r = –.378,
N = 64, p < .001; Subscale 3: r = –.520, N = 64, p <
.0001). Linear regression analysis revealed that TAS-20
total scores accounted for a large percentage (21.1%) of
the variance in BEES scores in the control group,
adjusted R2 = .211, F(1, 63) = 17.873, p < .0001.
Downloaded by [Stony Brook University] at 19:44 21 October 2014
Relationship between alexithymia, emotional
empathy, injury severity, and time since injury
Spearman R correlations failed to find a significant rela-
tionship between measures of alexithymia, emotional
empathy, and injury severity using PTA and GCS scores
as indices of severity (alexithymia and PTA: r = –.250, N
= 64, p > .05; alexithymia and GCS: r = .060, N = 64, p >
.05; emotional empathy and PTA: r = .272, N = 64, p >
.05; emotional empathy and GCS: r = –.275, N = 64, p >
.05). Similarly, Spearman R correlations failed to find a
significant relationship between measures of alex-
ithymia, emotional empathy, and time since injury (alex-
ithymia and time since injury: r = .217, N = 64, p > .05;
emotional empathy and time since injury: r = –.046, N =
64, p > .05).
DISCUSSION
The results of this study found that the frequency of
alexithymia after TBI (60.9%) was much higher than
that in a matched control group (10.9%) drawn from the
general population but comparable to the figure of
57.9% reported in a previous sample of TBI patients
(Wood & Williams, 2007). The present study also con-
firmed findings by Wood and Williams (2008), which
indicated that many TBI patients exhibit a loss of, or
reduction in, the ability to empathize. The proportion of
TBI cases reporting low emotional empathy (64.4%)
revealed a moderate significant difference to a group of
matched control cases (34.4%) drawn from the general
population, and this effect was seen in both males and
females. The known gender bias in empathy and the high
number of males in each group probably accounts for
the elevated rate of low emotional empathy in the con-
trol group. The consistency of these findings in various
groups of TBI patients provides support for the concept
of acquired alexithymia after TBI (Becerra et al., 2002).
Consistent with previous research examining the emo-
tional consequences of head trauma (Wood & Williams,
2007, 2008), no significant relationship was found
between either alexithymia or emotional empathy and
severity of injury, measured by either PTA or GCS
scores. Additionally, no significant relationship was
found between either alexithymia or emotional empathy
and time since injury. Therefore, it appears that the pres-
ence of alexithymia and emotional empathy following
TBI is not constrained by severity of injury or time since
injury variables.
In both TBI and control groups, significant moderate
negative correlations were found between alexithymia
(TAS-20 total scores) and emotional empathy (BEES)
scores. Linear regression analysis found that alexithymia
scores accounted for 21.1% of the variance in emotional
empathy scores in the control group, but only 9% in the
TBI group, even when controlling for the influence of
cognitive variables. This suggests that whilst a negative
relationship exists between alexithymia and emotional
empathy, the relationship is stronger in the absence of
head trauma. Outliers, ceiling and floor effects do not
appear to offer an explanation for this finding and
instead may reflect differences between the expression of
developmental and acquired aspects of alexithymia, or
the impact of limited insight in the TBI group.
Our results support early clinical (Krystal, 1979;
McDougall, 1989; Taylor, 1987) and research findings
(Davies et al., 1998; Moriguchi et al., 2007) that report
that alexithymia is associated with difficulty in under-
standing not only one’s own emotional state but also the
emotional state of others. Our results are also consistent
with previous TBI research that has reported poorly
modulated emotional reactions in patients who lack the
ability to represent the mental state or subjective per-
spective of others (Barrash, Tranel, & Anderson, 2000;
Bibby & McDonald, 2005; Channon & Crawford, 2000;
Heberlein, Padon, Gillihan, Farah, & Fellows, 2008;
Mah, Arnold, & Grafman, 2005; Milders, Ietswaart,
Crawford, & Currie, 2006, 2008; Stone, Baron-Cohen, &
Knight, 1998). Such “theory of mind” impairments can
be linked to a variety of social deficits, including an ego-
centric, self-centered attitude and indifference to the
opinions of others, characteristics that have been
observed clinically in those who have suffered TBI
(Wood, 2001; Worthington & Wood, 2008) and which
could be interpreted as reflecting a lack of emotional
empathy (Rowe, Bullock, Polkey, & Morris, 2001;
Wood & Williams, 2008). Such emotional deficits poten-
tially contribute to a range of interpersonal difficulties
that influence psychosocial outcome, reinforcing previ-
ous recommendations that neuropsychological examina-
tion after head trauma should include a careful
assessment of emotional factors as well as cognitive abil-
ity (Henry et al., 2006; Wood & Williams, 2007).
Clinical observations have noted an interesting disso-
ciation in some TBI patients who exhibit awareness of
inappropriate behavior displayed by others yet fail to
recognize the same behavior in themselves (Wood, 2001;
Worthington & Wood, 2008). This may be explained by
the absence of an expected negative correlation in the
TBI group between Subscale 1 of the TAS-20 (difficulty
identifying feelings) and the BEES, even though a nega-
tive correlation was present in the control group. These
findings, in the context of the present study, imply that
 ALEXITHYMIA AND EMOTIONAL EMPATHY FOLLOWING TBI
capacity for emotional empathy may operate independ-
ently of alexithymia after TBI, which possibly reflects
the impact of diffuse cerebral injury on different emo-
tional systems, mediated by complex bidirectional and
mutually inhibitory interconnections between the ventral
prefrontal cortex (VPFC) and the amygdala (Adolphs,
Baron-Cohen, & Tranel, 2002; Dougherty et al., 2004).
The VPFC is vulnerable to acceleration–deceleration
forces in TBI (Adams et al., 1982; Shaw, 2002), poten-
tially disrupting neural networks responsible for social
cognition, isolating cognitive appraisal of a stimulus
from its somatic marker, and thereby reducing the
person’s ability to experience the emotional attributes of
the stimulus (Adolphs, Tranel, Damasio, & Damasio,
1994; Bechara, Damasio, & Damasio, 2000; Shuren &
Grafman, 2002; Hornak et al., 1996; Tranel, Bechara, &
Denburg, 2002). As such, damage to the ventromedial
PFC may differentially impact upon the ability to recog-
Downloaded by [Stony Brook University] at 19:44 21 October 2014
nize one’s own emotions and the ability to empathize
with the emotional states of others.
The study has a number of limitations. Self-report
measures may be vulnerable to influence by a number of
variables, including a lack of self-awareness and biased
perception. Collateral information from relatives or sys-
tematic behavioral observations would be advisable in
future research. There is also the potential for bias in the
selection of patients used in this study, because they
were all referred on the basis that they exhibited prob-
lems in everyday behavior. However, the results of this
study provide objective evidence to support the observa-
tions of relatives and clinicians that lead to the initial
referral for neuropsychological assessment. Another
limitation relates to the possible presence of alexithymia
and low empathy prior to injury. We accept that even
though the TBI group did not report a preaccident his-
tory of psychiatric, neurological, or personality prob-
lems potentially interpretable as alexithymia or a lack of
emotional empathy, subclinical levels may have been
present. However, relatives who were present during the
initial clinical interview of these patients did not report
the presence of these characteristics. Indeed, most rela-
tives pointed to a lack of warmth or love as a postacci-
dent development that placed a burden on their
relationship. This implies that if any problems were
present preinjury they were both subtle and exacerbated
by head trauma. Future research will need to examine
this more carefully.
The use of Glasgow Coma Scale scores and
posttraumatic amnesia as indices of injury severity pro-
duce a further limitation. The predictive validity of these
indices for functional outcome is inconclusive, and GCS
scores have shown poor predictive validity for long-term
outcome (Healey et al., 2003; McCullagh, Oucherlony,
Protzner, Blair, & Feinstein, 2001; Zafonte et al., 1997).
We also accept that other measures of cognitive func-
tioning might have produced different results. The use of
the three subscale scores of the TAS-20 also acts as a lim-
itation. Some studies have failed to replicate the three-
subscale structure (Kooiman, Spinhoven, & Trijsburg,
2002), whilst others have confirmed it (Loas et al., 2001).
However, whilst the three-subscale structure has not yet
265
been investigated in a head-injured sample, it has been
used in other head injury research (Henry et al., 2006;
Wood & Williams, 2007). Future research should also
examine the reliability, validity, and psychometric prop-
erties of the TAS-20 and BEES when used in a TBI
cohort, to improve the ability to assess and recognize the
presence of alexithymia and low emotional empathy
following head trauma.
Whilst the results of this study confirm that TBI can
result in both alexithymia and low emotional empathy, it
is not possible to directly implicate any particular cere-
bral structures in the TBI group because of the diffuse
nature of head trauma, even though frontal involvement
is suspected. Moriguchi et al. (2007) and Singer et al.
(2006) previously examined neural activity to empathic
situations within the pain matrix, comparing activity
across alexithymia groups, and Nummenmaa, Hirvonen,
Parkkola, and Hietanen (2008) examined neural activity
of participants when presented with photographs depict-
ing people in neutral everyday situations (cognitive
empathy) or suffering serious threat or harm (emotional
empathy). These studies provide a methodological
framework for future research to investigate the cerebral
basis of alexithymia and emotional empathy following
TBI. Finally, although we have established a negative
relationship between alexithymia and emotional empa-
thy, supporting the broad assumption that awareness of
emotional states in oneself appears to be a prerequisite
to recognizing such states in others, this study is not able
to determine the precise nature of this relationship.
In spite of these limitations, the authors believe that
the findings of this study reiterate the proposal that neu-
ropsychological examination should carefully assess
emotional changes following head trauma because disor-
ders of emotion recognition either in oneself or in others
can adversely impact interpersonal relationships and
psychosocial outcome. Therefore, if recognized early in
recovery, such deficits could be a focus of rehabilitation.
Future research should therefore examine the relation-
ship between alexithymia, emotional empathy, and psy-
chosocial outcome and also investigate relationships
between alexithymia and empathy in more detail, paying
attention to the many constituent parts of empathy (i.e.,
perspective taking, mutual sharing and understanding,
compassionate empathy), and related concepts such as
theory of mind.
Original manuscript received 21 November 2008
Revised manuscript accepted 17 April 2009
First published online 22 June 2009
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