Role of theory of mind in emotional awareness and alexithymia: Implications for conceptualization and measurement

•Alexithymia may consist of more benign “anomia” and more severe “agnosia” versions.•The latter involves an impairment in mental representation of emotional states.•These may be captured by the TAS-20 and LEAS, respectively.•The usefulness of this distinction for the treatment of alexithymia is described. The goal of this study was to determine whether alexithymia, which is characterized by difficulty in recognizing and describing emotions, is associated with impairments in the ability to mentally represent emotional states. We studied 89 outpatients including 29 conversion disorder patients, 30 functional somatic syndrome [e.g. fibromyalgia] patients and 30 medical controls. Groups did not differ on affective or cognitive Theory of Mind (ToM) measures, the Levels of Emotional Awareness Scale (LEAS) or the Twenty-Item Toronto Alexithymia Scale (TAS-20) after adjusting for Positive and Negative Affect Scale (PANAS) variables. Across all patients, LEAS but not TAS-20 correlated positively with affective and cognitive ToM measures after adjusting for PANAS scores. Impairments in ToM functioning influence LEAS performance but not TAS-20 scores. These findings support the distinction between a milder “anomia” form of alexithymia associated with impaired emotion naming and a more severe “agnosia” form associated with impaired mental representation of emotion.