Psychometric Properties of the Arabic Translation of the Shitsu-Taikan-Sho (alexisomia) Scale (AR-STSS) in adults

Psychometric Properties of the Arabic Translation of the Shitsu-Taikan-Sho (alexisomia) Scale (AR-STSS) in adults | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Psychometric Properties of the Arabic Translation of the Shitsu-Taikan-Sho (alexisomia) Scale (AR-STSS) in adults Serena Samaha, Diana Malaeb, Fouad Sakr, Mariam Dabbous, Souheil Hallit, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5353747/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective Our aim in this study is to assess the psychometric properties of the Arabic version of the Shitsu-Taikan-Sho (Alexisomia) Scale (Ar-STSS) in a sample of Lebanese adults. Methods Data for this cross-sectional study was gathered using a Google form link. A sample of 758 Lebanese adults (61.2% females, mean age of 30.27 ± 13.80 years) completed an online questionnaire. Results According to CFA, the initial model's fit was poor: χ 2 /df = 1266.51/227 = 5.58, RMSEA = .099 (90% CI .094, .104), SRMR = .114, CFI = .748, TLI = .719. The Turkish model's CFA indicated a better fit: χ 2 /df = 474.70/132 = 3.60, RMSEA = .075 (90% CI .067, .082), SRMR = .071, CFI = .886, TLI = .867. The second-order model's fit indices were good: χ 2 /df = 474.70/132 = 3.60, RMSEA = .075 (90% CI .067, .082), SRMR = .071, CFI = .886, TLI = .867. The composite reliability of the scores was adequate (ω = .89). No significant difference was observed between sex in terms of alexisomia (53.19 ± 13.58 vs 52.28 ± 11.93; t (465) = .76; p = .450). Higher alexisomia were significantly associated with higher alexithymia (r = .50; p < .001), depression (r = .37; p < .001) and anxiety (r = .26; p < .001). Conclusion The linguistically validated Arabic version of the Shitsu-Taikan-Sho (Alexisomia) Scale can be used to screen for alexisomia among Lebanese adults. Shitsu-Taikan-Sho (Alexisomia) Scale Psychometric properties Arabic Figures Figure 1 INTRODUCTION Alexisomia, or “no words to describe bodily states”, is a “clinical concept that refers to the characteristics of having difficulty in awareness and expression of bodily (somatic) emotions or sensations” (Ikemi & Ikemi, 1986 ; Kanbara & Fukunaga, 2016 ; Moriguchi & Komaki, 2013 ; Oka, 2020 ). This concept is implied by "shitsu-taikan sho," where "shitsu" means deficiency, "taikan" denotes somatic emotions and sensations, and "sho" indicates a condition or symptom (Oka, 2020 ). Dr. Yujiro Ikemi, the pioneer of psychosomatic medicine in Japan (Ikemi, 1979 ), first proposed this concept in 1979 based on his observations that patients with psychosomatic diseases struggle with the awareness and expression of not only their emotions, known as alexithymia, but also somatic emotions and sensations, known as alexisomia (Oka, 2020 ; Oka & Lkhagvasuren, 2022 ). There have been suggestions that psychosomatic diseases may develop and persist as a result of alexisomia (Kanbara & Fukunaga, 2016 ; Oka, 2020 ). Alexithymia, a personality feature originally recognized by P.E. Sifneos in 1973 and defined by a "difficulty in identifying, experiencing, and expressing emotions", has been found to have a significant role in the development of alexisomia in patients with psychosomatic disorders (Sifneos, 1973 ). Ikemi observed in 1977 that in numerous cases of alexithymia, where a difficulty in the awareness and expression of feelings is seen, there have been additionally a difficulty in experiencing awareness and expression of bodily feelings (Oka, 2020 ). This led to the conclusion that the majority of diseases in the modern world, particularly those affecting adults, are caused by a lack of awareness of one's own body's emotions. Thus, alexisomia places more emphasis on body awareness (interoceptive/proprioceptive), whereas alexithymia places more emphasis on emotions overall (Oka & Lkhagvasuren, 2022 ). Moreover, alexithymia, depression, anxiety, and stress were all proven to be dimensional phenomena that appear on a continuum within the society (Kotov et al., 2017 ). With alexithymia being moderately to strongly linked with levels of depression and anxiety symptoms in numerous studies (Li et al., 2015 ; Marchesi et al., 2000 ; Müller et al., 2003 ), alexithymia was also seen as a substantial transdiagnostic risk factor for many issues: substance abuse, eating disorders, anxiety disorders, depression, personality disorders and psychosomatic diseases (Bankier et al., 2001 ; Taylor et al., 1999 ). However, since alexisomia is a relatively new field of study and not entirely distinct from alexithymia, current research is still in its early stages, with a strong need to explore its correlations and implications. As the idea of alexisomia first surfaced, early observational research carried out in Japan revealed that people with psychosomatic problems exhibit characteristics of alexisomia (Oka, 2020 ). Due to the variability and inconsistency in defining alexisomia and the differences in the measurement techniques across the studies, it became crucial to establish standardized methods for defining and evaluating this emerging clinical concept. Prior to the Shitsu-Taikan-Sho Scale (STSS) being introduced in 2012, there was no dedicated self-report instrument available for alexisomia assessment (Oka, 2020 ). The Shitsu-Taikan-Sho Scale (STSS) The Shitsu-Taikan-Sho Scale (STSS) is a self-administered questionnaire that measures alexisomia. It has 23 items that are assessed on a 5-point Likert scale (Arimura et al., 2012 ; Oka, 2020 ). The STSS is composed of three subscales: Difficulty Identifying Bodily Sensations (DIB), Overadaptation (OA), and Lack of Health Management (LHM) related to bodily feelings (Hasuo et al., 2022 ). The DIB subscale addresses a lack of knowledge regarding allostatic stress and homeostasis-related bodily signals, both normal and disordered. The OA subscale tackles the tendency to prioritize social expectations of one's own body experiences. The LHM subscale focuses on the inadequate medical attention to bodily sensations (Arimura et al., 2012 ; Oka, 2020 ). The total score and subscores of the original Japanese Shitsu-Taikan-Sho Scale showed sufficient internal consistency (α = 0.70–0.84) and test-retest reliability (r = 0.71–0.81) in the results (Oka, 2020 ). The Mongolian version of the Shitsu-Taikan-Sho Scale, consisting of 21 items, showed a Cronbach’s alpha value of 0.860, confirming its good internal consistency, and test-retest reliability analysis displayed good reliability (ICC = 0.791) (Lkhagvasuren et al., 2024 ). Finally, the Turkish version of the Shitsu-Taikan-Sho Scale consisted of 18 items only, with a Cronbach’s alpha coefficient ranging from 0.711 to 0.825 (Aksu et al., 2023 ). The present study A global transition from communicable to noncommunicable chronic illnesses has occurred in recent decades, with Lebanon - a developing country with a unique cultural background - experiencing this change. Developing nations like Lebanon have been more severely impacted by this shift than developed nations (Bollyky et al., 2017 ; Bourne, 2023 ). Additionally, Lebanon, a low-income country in the Middle East, has been dealing for years with civil unrest, economic collapse, governmental corruption, COVID-19 pandemic, and the deadly 2020 Beirut Blast (El Hajj, 2021 ). Consequently, this research aims to assess the psychometric properties of the Arabic version of the Shitsu-Taikan-Sho (Alexisomia) Scale in Lebanese adults. The study will provide substantial insight into the validity and reliability of the Arabic version of the STSS, which is essential to establishing treatments to improve the Lebanese population's physical and mental health. The Arabic Shitsu-Taikan-Sho (Alexisomia) Scale (Ar-STSS) is expected to: (1) replicate the three-factor structure that was first proposed; (2) exhibit strong composite validity and invariance of measurements by sex (males vs. females); and (3) show sufficient patterns of correlations with measures of alexithymia, depression and anxiety. METHODS Study design and sampling This cross-sectional study was performed during April 2024. The snowball sampling method was used to gather data using a shared Google Form link. The research team first contacted acquainted adults, who were subsequently requested to share the link with their friends and relatives within the same age group. Included were adult Lebanese participants above 18 years of age residing in Lebanon. Excluded were individuals who have not finished filling the questionnaire. The survey was anonymous, with participation being completely voluntary and without compensation. Forward and back translation procedure Prior to its application in the present study, the Shitsu-Taikan-Sho (alexisomia) Scale was translated in order to make it appropriate for the Arabic language and cultural setting. A single bilingual translator, whose native language is Arabic, carried out the forward translation. A panel of experts examined the translated Arabic version that was obtained. After that, a backward translation was carried out. The back-translated questionnaire was then compared by an expert committee to the original one. Until all ambiguities vanished, the forward-back translation process was repeated. Following international guidelines, the translation attempted to achieve semantic equivalency between the original measures and their Arabic equivalents (Van Widenfelt et al., 2005 ). A pilot study comprising 30 participants was carried out to confirm to ensure that each question was comprehended; no adjustments were made following the pilot research. Measures The Shitsu-Taikan-Sho Scale (STSS) is a self-administered questionnaire that measures alexisomia. It has twenty-three items that are assessed on a 5-point Likert scale, with a total score ranging from 23 to 115 (Arimura et al., 2012 ; Oka, 2020 ). The STSS subscales include a three-dimensional scale: Difficulty Identifying Bodily Sensations (DIB), Overadaptation (OA), and Lack of Health Management (LHM) related to bodily feelings (Hasuo et al., 2022 ). The DIB subscale consists of nine questions (items 1, 5, 6, 10, 12, 14, 15, 18, and 19) with an average score of 18.1 ± 5.6 points among college students in Japan, that address a dearth of knowledge on body signals pertaining to homeostasis and allostatic stress, both normal and disordered. The OA subscale consists of six questions (items 3, 7, 13, 17, 20, and 22) with an average score of 14.2 ± 4.5 points, that address the propensity to disregard bodily sensations in order to prioritize social expectations. The LHM subscale, which included seven questions (reverse-scored items 2, 4, 8, 9, 11, 16, and 21, excluding item 23) with an average score of 21.4 ± 3.8 points, focused on the provision of insufficient medical attention in response to bodily sensations (Arimura et al., 2012 ; Oka, 2020 ). The sum of the responses to each of the 23 items determines the final score, while the responses within each subscale are added up to determine the subscale score. Thus, out of 115 total points, the average overall score was 56.3 ± 10.2. The Generalized Anxiety Disorder (GAD-5). Validated in Lebanon (preprint article), the GAD-5 is a 5-item scale evaluating anxiety symptoms experienced in the last 2 weeks (Goldberg et al., 2012 ; Goldberg et al., 2017 ). Participants evaluate how well each statement described their recent experiences on a 10-point Likert scale (“0 = does not describe me and 10 = describes me exactly). Higher scores indicate higher GAD (ω = .93 / α = .93). Patient Health Questionnaire (PHQ-9). The PHQ-9, a nine-item self-report measure validated in Arabic (Sawaya et al., 2016 ), is used to measure and track the severity of depression. As a severity measure, the PHQ-9 score can range from 0 to 27, since each of the 9 items can be scored from 0 (not at all) to 3 (nearly every day). An item was also added to the end of the diagnostic portion of the PHQ-9 asking patients who checked off any problems on the questionnaire: “How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?”. Higher scores indicate higher level of depression (ω = .89 / α = .89). Toronto Alexithymia Scale (TAS-20). The Toronto Alexithymia Scale (TAS-20), validated in Arabic (El Frenn et al., 2022 ), is an alexithymia measurement tool with 20 items developed by Bagby et al. (Bagby et al., 1994 ). Twenty statements on the scale, ranked from 1 to 5 using 5-point Likert scale, represent an individual's incapacity to recognize and characterize their feelings and divided into three subscales to assess three dimensions: Difficulty Identifying Feelings (DIF) subscale, Difficulty Describing Feelings (DDF) subscale, and Externally-Oriented Thinking (EOT) subscale. TAS-20 scores have a cut-off of 51 for non-alexithymia, 52–60 for potential alexithymia, and 61 or higher for alexithymia. Analytic Strategy The dataset had no missing responses. Using SPSS AMOS version 29, a Confirmatory Factor Analysis (CFA) was conducted on the complete sample data. The computed minimum sample size varied from 69 to 460 participants, providing sufficient statistical power for the CFA, based on whether the sample had 3 to 20 times the number of variables in the scale (Mundfrom et al., 2005 ). The parameter estimations were obtained using the maximum likelihood technique. The normed chi-square (χ²/df), the Standardized Root Mean Square Residual (SRMR), the Tucker-Lewis Index (TLI), the Steiger-Lind Root Mean Square Error of Approximation (RMSEA), and the Comparative Fit Index (CFI) were among the fit indices that were calculated. Adequate values were ≤ 5 for χ²/df, ≤ .08 for RMSEA, ≤ .05 for SRMR and .90 for CFI and TLI (Hu & Bentler, 1999 ). Items with loading factors less than 0.33 were eliminated. Following the initial failure to prove multivariate normality (Bollen-Stine bootstrap p = .002), we used a non-parametric bootstrapping technique. Sex invariance Sex invariance of STSS scores was evaluated by a multi-group CFA with the total sample (Chen, 2007 ). Three layers of measurement invariance testing were conducted: configural, metric, and scalar (Vandenberg & Lance, 2000 ). We considered ΔCFI ≤ .010, ΔRMSEA ≤ .015, or ΔSRMR ≤ .010 (with a ΔSRMR threshold of .030 for factorial invariance) as indicators of invariance (Fekih-Romdhane et al., 2023 ). McDonald's ω and Cronbach's α were used to assess composite reliability; values greater than .70 indicated adequate composite reliability (Dunn et al., 2014 ). Normality was confirmed because the skewness and kurtosis values for each item on the scale ranged from − 1 to + 1 (Hair Jr et al., 2023 ). The Student's t-test was employed to compare two means, and the Pearson test was conducted to evaluate the association between STSS scores and other scales. RESULTS Participants A total of 758 participants − 61.2% of whom were female - completed the survey; their average age was 30.27 ± 13.80 years [range: 18 to 90]. Additionally, the average Household Crowding Index (HCI) was 1.23 ± .57 individuals per room, and 74.5% of the population held a university degree. Confirmatory Factor Analyses According to CFA, the initial model's fit (Oka, 2020 ) was poor: χ 2 /df = 1266.51/227 = 5.58, RMSEA = .099 (90% CI .094, .104), SRMR = .114, CFI = .748, TLI = .719. The Mongolian model's CFA (Lkhagvasuren et al., 2024 ) was relatively modest: χ 2 /df = 467.21/87 = 5.37, RMSEA = .097 (90% CI .088, .106), SRMR = .067, CFI = .845, TLI = .812. The Turkish model's CFA (Aksu et al., 2023 ) indicated a better fit: χ 2 /df = 474.70/132 = 3.60, RMSEA = .075 (90% CI .067, .082), SRMR = .071, CFI = .886, TLI = .867. The second-order model's fit indices were good: χ 2 /df = 474.70/132 = 3.60, RMSEA = .075 (90% CI .067, .082), SRMR = .071, CFI = .886, TLI = .867. All of the standardized factor loading estimations were sufficient (Fig. 1 ). For the entire sample, the composite reliability of the scores was adequate (ω = .89 / α = .89). Sex Invariance At the configural, metric, and scalar levels, we were able to demonstrate the invariance across sex (Table 1 ). No significant difference was observed between females and males in terms of alexisomia (53.19 ± 13.58 vs 52.28 ± 11.93; t (465) = .76; p = .450). Table 1 Measurement Invariance of the Shitsu-Taikan-Sho (alexisomia) Scale across Sex in the total sample. Model CFI RMSEA SRMR Model Comparison ΔCFI ΔRMSEA ΔSRMR Configural .874 .056 .087 Metric .872 .055 .094 Configural vs metric 002 .001 .007 Scalar .863 .056 .094 Metric vs scalar .009 .001 < .001 Note. CFI = Comparative fit index; RMSEA = Steiger-Lind root mean square error of approximation; SRMR = Standardised root mean square residual. Concurrent validity Higher alexisomia scores were significantly associated with higher alexithymia (r = .50; p < .001), depression (r = .37; p < .001) and anxiety (r = .26; p < .001). DISCUSSION According to the current study, the Arabic version of the STSS is adequate to be used for the assessment of alexisomia in the Lebanese population, through its good factor structure,adequate reliability and validity. Moreover, it can be used for the assessment of alexisomia in both genders. A composite reliability of .89 was found for the Arabic STSS total score, which reflects a high level of internal consistency and the consistency of the measurement's results. The Cronbach’s alpha coefficient was between 0.70 and 0.84 for the original Japanese version (Oka, 2020 ), 0.860 for the Mongolian version (Lkhagvasuren et al., 2024 ), and 0.825 for the Turkish version (Aksu et al., 2023 ). Thus, with a higher internal consistency between the previously validated versions of Shitsu-Taikan-Sho Scale, the Arabic version of the STSS is reliably capturing the same underlying concept, making the results from this tool trustworthy and stable. Factor structure According to CFA, the initial model's fit was poor (Oka, 2020 ). In our study, the high χ²/df ratio (= 5.58) with values greater than 3 showing a poor fit, elevated RMSEA (= .099) just below the standard threshold of .10, high SRMR (= .114) above the accepted threshold of .08, and low CFI (= .748) and TLI (= .719) below the recommended threshold of .90, all indicate that the model does not adequately represent the data. This implies that in order to improve the model's fit to the data, it may need to be modified and revised by re-evaluating the model structure, adding or removing factors, or considering alternative models. Moreover, the Mongolian model's CFA (Lkhagvasuren et al., 2024 ) in the present study was relatively modest with some indices suggesting the fit could be improved. While the SRMR is acceptable, the χ²/df ratio, RMSEA, CFI, and TLI suggest that the model may not be an ideal fit and may require modifications or enhancements to better align with the data. This might be explained by the differences between Lebanese, Japanese, and Mongolian populations in terms of an assortment of cultural, historical, socioeconomic, and demographic characteristics as well as their perceptions of mental health between the Middle East and the Far East. This can be explained by the absence of Far East historical relics in the Middle East, and its recent pursuit to implement soft power through language acquisition, traditional sports, cultural promotion, and exchange (Choudhury, 2018 ). These elements collectively shape how individuals from each population perceive and communicate psychological phenomena. Conversely, the Turkish model's CFA (Aksu et al., 2023 ) indicated a better fit compared to the Mongolian and original model in our current research. The Turkish model fits the data more reasonably, according to the χ²/df ratio, RMSEA, and SRMR, although the CFI and TLI are slightly below the ideal threshold but still point to an overall good fit. Lebanese linguistic and communication facets may be more closely aligned with the Turkish model. Turkish and Arabic are close to each other in the global linguistic realm. These languages have entwined histories, changing throughout time and having geographic links to language use. Additionally, Turkish and Arabic (the official language of Lebanon) have some linguistic/cultural commonalities that might influence how emotional expressions are perceived and assessed. The common features in societal norms and practices between Turkey and Lebanon comes from their religious, economic, and social characteristics (Kalafatoglu & Mendoza, 2017 ), making the Turkish model more contextually relevant in our study. In contrast, Mongolian cultural practices and values are quite different, which might cause scale items to be misinterpreted. Therefore, the Turkish model may be less effective in capturing alexisomia compared to the Mongolian and original version, since the social structures in Lebanon may be more similar to those in Turkey in terms of family dynamics and societal roles. Sex invariance Sex disparities in the reporting of somatic symptoms have been shown in a number of research conducted in various contexts (Nakao et al., 2001 ). However, at the configural, metric, and scalar levels, we were able to demonstrate the invariance across sex. No discernible difference in alexisomia was observed between the sexes, in line with previous studies (Gan et al., 2016 ; Lkhagvasuren et al., 2024 ; Oka & Lkhagvasuren, 2022 ). Men and women may perceive and process emotions similarly (Fischer et al., 2018 ), resulting in analogous levels of alexisomia. Indeed, there may not be significant gender differences in alexisomia since males and females may have similar biological sensitivity to emotional and bodily stimuli (Carvalho et al., 2012 ; Codispoti et al., 2008 ; Hillman et al., 2004 ). Moreover, psychological factors similarly prominent in both genders may also have an impact on alexisomia. Concurrent validity Our findings showed that higher alexisomia is associated with higher alexithymia. Emotional awareness and somatic interoceptive awareness are vital for humans’ psychosomatic health (Kanbara & Fukunaga, 2016 ). One prevalent trait linked to a lack of emotional awareness in relation to psychosomatic illnesses is alexithymia. Conversely, alexisomia refers to the lack of somatic awareness. As we know, a strong connection exists between the body and emotions, particularly, the more subtle an emotion is, the more marked its effects on the body. Additionally, a decline in emotional awareness is linked with a reduced sensitivity to bodily sensations, explaining why somatic awareness is essential for emotional awareness (Kanbara & Fukunaga, 2016 ). Consequently, the "body" and the "mind" are essentially two facets of the same entity (Kanbara & Fukunaga, 2016 ). As a result, alexithymia and alexisomia have significant overlap and are not completely divergent. Two studies suggest that alexisomia is strongly linked to alexithymia (Ikemi & Ikemi, 1986 ; Oka, 2020 ). There is a growing body of research on alexisomia and its relationship to alexithymia(Kanbara & Fukunaga, 2016 ). Ikemi acknowledged, “in many cases of alexithymia, where there is an observed difficulty in the awareness and expression of feelings, there also seems to be a difficulty in the awareness and expression of bodily feelings” and saw characteristics of both alexithymia and alexisomia in people suffering from psychosomatic illnesses (Ikemi & Ikemi, 1986 ). According to Oka, alexisomia is an extension of alexithymia (Oka, 2020 ). By looking at neuroimaging studies, Moriguchi and Komaki investigated the connection between alexithymia and alexisomia (Moriguchi & Komaki, 2013 ). Since bodily states act as a context for emotions, shaping affective processes in a manner similar to the effects of external contexts and occasion setters (Pearce & Bouton, 2001 ), they concluded that somatic awareness is the foundation of emotional awareness (Kanbara & Fukunaga, 2016 ). Furthermore, greater alexisomia scores were substantially associated with higher levels of anxiety and depression. The amount of literature on alexisomia is quite modest, given that it is an emerging topic. To our knowledge, this study is the first to address the association between three major psychological concerns; alexisomia, depression and anxiety. Individuals with high alexisomia often “have difficulties in expressing how their bodies feel” (Ikemi & Ikemi, 1986 ), which thus lead to poor emotional regulation as proven by the connection between the alexisomia subscale OA and emotional regulation (Aksu et al., 2023 ). This can lead to elevated levels of stress and anxiety, as individuals may find it difficult to properly control their emotions. As proven by the stress-alexithymia hypothesis, “lacking emotional awareness leads to ineffective coping, which prolongs the exposure to stressors and predisposes to mental health problems” (Martin & Pihl, 1985 ). Therefore, they may be more sensitive to stressors, having a hard time coping with them, exacerbating by then the anxiety and depression, supported by multiple studies (Dong et al., 2013 ; Spada et al., 2008 ). Until now, studies on alexisomia and its connections to other psychological factors have not been sufficiently conducted. Future research is recommended in order to understand in depth the correlation between alexisomia and mental health. Clinical Implications Validating and assessing the psychometric properties of the STSS in an Arab-speaking society within a developing Middle Eastern nation is a major contribution to the field. As the Arabic STSS provides an accurate assessment of alexisomia, it can be highly useful in clinical settings. By using it, medical professionals can gain a deeper understanding of patients' challenges in recognizing and expressing their bodily emotions, important for precise diagnosis and efficient treatment planning. Thus, improving overall quality of care and enabling better patient outcomes by providing a detailed insight of the patient's emotional experience. Limitations Some limitations should be acknowledged and addressed in future research. Information bias might have occurred if patients misinterpreted the questions or over/underestimated the responses. Response bias may be introduced by using self-report measures and convenience web-based sampling methods, thus affecting the representativeness of the study's sample. In addition, only a general population sample was included in the present study. We suggest conducting further investigation on the psychometric properties of the Arabic STSS in clinical populations with the inclusion of control groups in order to make accurate conclusions regarding individuals with alexisomia. The inclusion of Arabic-speaking adults from only one Arab nation—Lebanon—is another drawback. Although Arab countries share some social, religious, and cultural similarities (Makhlouf Obermeyer, 2015 ; Sewilam et al., 2015 ), significant variances do exist, emphasizing the necessity for further cross-cultural validation of the Ar-STSS in other regional contexts. CONCLUSION Our contribution to the corpus of existing literature is to deepen our comprehension of the STSS's psychometric qualities in an unusual context and language. Since language limitations are a major hindrance to appropriate medical communication and management, translation of the STSS to Arabic and validation of its psychometric properties was essential. The linguistically validated Arabic version of the STSS can be used to screen for alexisomia among Lebanese adults. To validate our findings and extend the use of the Arabic versions of this scale, further research is needed in additional Arabic-speaking nations. Declarations Ethics Approval and Consent to Participate : The Lebanese International University's School of Pharmacy ethics committee granted this study ethics permission (2024ERC-042-LIUSOP). A written informed consent was obtained from each participant when completing the online form. All methods were performed in accordance with the relevant guidelines and regulations (in accordance with the Declaration of Helsinki). Consent for publication: Not applicable. Availability of data and materials: The data that support the findings of this study are available from the corresponding author but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the ethics committee. Competing interests: The authors have nothing to disclose. Funding: None. Author contributions: F.F.R, S.O and S.H designed the study; D.M, F.S and M.D collected the data, S.S drafted the manuscript; S.H carried out the analysis and interpreted the results; all authors reviewed the final manuscript and gave their consent. Clinical trial number : Not applicable Acknowledgments: The authors would like to thank all participants. 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Hillman CH, Rosengren KS, Smith DP. Emotion and motivated behavior: postural adjustments to affective picture viewing. Biol Psychol. 2004;66(1):51–62. Hu Lt, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Struct equation modeling: multidisciplinary J. 1999;6(1):1–55. Ikemi Y. Psychophysiology as the starting point of education. Jpn J Transactional Anal. 1979;4:1–10. Ikemi Y, Ikemi A. An oriental point of view in psychosomatic medicine. Psychother Psychosom. 1986;45(3):118–26. Kalafatoglu T, Mendoza X. The impact of gender and culture on networking and venture creation: An exploratory study in Turkey and MENA region. Cross Cult Strategic Manage. 2017;24(2):332–49. Kanbara K, Fukunaga M. Links among emotional awareness, somatic awareness and autonomic homeostatic processing. Biopsychosoc Med. 2016;10(1):16. Kotov R, Krueger RF, Watson D, Achenbach TM, Althoff RR, Bagby RM, Brown TA, Carpenter WT, Caspi A, Clark LA. The Hierarchical Taxonomy of Psychopathology (HiTOP): A dimensional alternative to traditional nosologies. J Abnorm Psychol. 2017;126(4):454. Li S, Zhang B, Guo Y, Zhang J. The association between alexithymia as assessed by the 20-item Toronto Alexithymia Scale and depression: A meta-analysis. Psychiatry Res. 2015;227(1):1–9. Lkhagvasuren B, Batkhuyag E, Tumurbaatar E, Urtnasan T, Tsengel D, Tumur-Ochir G, Oka T. Psychometric properties of the Mongolian version of shitsu-taikan-sho (alexisomia) in young adults. Sci Prog. 2024;107(1):00368504231225075. Makhlouf Obermeyer C. (2015). Adolescents in Arab countries: health statistics and social context. DIFI Family Research and Proceedings , 2015 (1), 1. Marchesi C, Brusamonti E, Maggini C. Are alexithymia, depression, and anxiety distinct constructs in affective disorders? J Psychosom Res. 2000;49(1):43–9. Martin JB, Pihl R. The stress-alexithymia hypothesis: theoretical and empirical considerations. Psychother Psychosom. 1985;43(4):169–76. Moriguchi Y, Komaki G. Neuroimaging studies of alexithymia: physical, affective, and social perspectives. Biopsychosoc Med. 2013;7:1–12. Müller J, Bühner M, Ellgring H. Relationship and differential validity of alexithymia and depression: a comparison of the Toronto Alexithymia and Self-Rating Depression Scales. Psychopathology. 2003;36(2):71–7. Mundfrom DJ, Shaw DG, Ke TL. Minimum sample size recommendations for conducting factor analyses. Int J Test. 2005;5(2):159–68. Nakao M, Fricchione G, Zuttermeister PC, Myers P, Barsky AJ, Benson H. Effects of gender and marital status on somatic symptoms of patients attending a mind/body medicine clinic. Behav Med. 2001;26(4):159–68. Oka T. Shitsu-taikan-sho (alexisomia): a historical review and its clinical importance. Biopsychosoc Med. 2020;14:1–9. Oka T, Lkhagvasuren B. Effects of practicing yoga on alexisomia: an open-label trial. Biopsychosoc Med. 2022;16(1):14. Pearce JM, Bouton ME. Theories of associative learning in animals. Ann Rev Psychol. 2001;52(1):111–39. Sawaya H, Atoui M, Hamadeh A, Zeinoun P, Nahas Z. Adaptation and initial validation of the Patient Health Questionnaire–9 (PHQ-9) and the Generalized Anxiety Disorder–7 Questionnaire (GAD-7) in an Arabic speaking Lebanese psychiatric outpatient sample. Psychiatry Res. 2016;239:245–52. Sewilam AM, Watson AM, Kassem AM, Clifton S, McDonald MC, Lipski R, Deshpande S, Mansour H, Nimgaonkar VL. Suggested avenues to reduce the stigma of mental illness in the Middle East. Int J Soc Psychiatry. 2015;61(2):111–20. Sifneos PE. The prevalence of ‘alexithymic’characteristics in psychosomatic patients. Psychother Psychosom. 1973;22(2–6):255–62. Spada MM, Nikčević AV, Moneta GB, Wells A. Metacognition, perceived stress, and negative emotion. Pers Indiv Differ. 2008;44(5):1172–81. Taylor GJ, Bagby RM, Parker JD. Disorders of affect regulation: Alexithymia in medical and psychiatric illness. Cambridge University Press; 1999. Van Widenfelt BM, Treffers PD, De Beurs E, Siebelink BM, Koudijs E. Translation and cross-cultural adaptation of assessment instruments used in psychological research with children and families. Clin Child Fam Psychol Rev. 2005;8:135–47. Vandenberg RJ, Lance CE. A review and synthesis of the measurement invariance literature: Suggestions, practices, and recommendations for organizational research. Organizational Res methods. 2000;3(1):4–70. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5353747","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":382436346,"identity":"4c44fae5-8d45-42fa-9fd6-adb868775259","order_by":0,"name":"Serena Samaha","email":"","orcid":"","institution":"Holy Spirit University of Kaslik","correspondingAuthor":false,"prefix":"","firstName":"Serena","middleName":"","lastName":"Samaha","suffix":""},{"id":382436347,"identity":"4ce1b55c-baab-4010-a2ac-534c135c181e","order_by":1,"name":"Diana Malaeb","email":"","orcid":"","institution":"Gulf Medical University","correspondingAuthor":false,"prefix":"","firstName":"Diana","middleName":"","lastName":"Malaeb","suffix":""},{"id":382436348,"identity":"a311d991-dde7-439a-842e-342188558a65","order_by":2,"name":"Fouad Sakr","email":"","orcid":"","institution":"Lebanese International University","correspondingAuthor":false,"prefix":"","firstName":"Fouad","middleName":"","lastName":"Sakr","suffix":""},{"id":382436349,"identity":"1b67428d-13b7-4ade-822a-d61eb144a91a","order_by":3,"name":"Mariam Dabbous","email":"","orcid":"","institution":"Lebanese International University","correspondingAuthor":false,"prefix":"","firstName":"Mariam","middleName":"","lastName":"Dabbous","suffix":""},{"id":382436350,"identity":"dbcd4151-ed94-404a-a6e4-be1aff2fc4ee","order_by":4,"name":"Souheil Hallit","email":"","orcid":"","institution":"Holy Spirit University of Kaslik","correspondingAuthor":false,"prefix":"","firstName":"Souheil","middleName":"","lastName":"Hallit","suffix":""},{"id":382436351,"identity":"5e7578b5-ae91-4479-9161-5ca724c653ee","order_by":5,"name":"Feten Fekih-Romdhane","email":"","orcid":"","institution":"Hôpital Razi de La Manouba","correspondingAuthor":false,"prefix":"","firstName":"Feten","middleName":"","lastName":"Fekih-Romdhane","suffix":""},{"id":382436352,"identity":"22783ab9-3f64-4501-9790-2841c5223495","order_by":6,"name":"Sahar Obeid","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYFACHhBxgIGNIfnwg48NIA5j4wEitaSlGc5sYJAAamkgTgsDQ46BNC9YC4SLE8i3nz34uaLijhwfe4KBse0Omzrd9sNAW2psonFpMTiTlyx55swzYzaeBwmPc8+kSZidSQRqOZaW24BLC9A9ko1thxPbJBIOGOe2HZYwOwDUwthwGKcW+f43xj+BWurbJBIbpC1BWs4/xK+F4UaOGciWBDaJZAZpRpCWGwRsMbjxxsyy4cwzwzaeZ2yGvW1pkttuAG1JwOMX+f4c45sNFXfk5dvzPz/42WbDb3Y+/eGDDzU2uB2GHSSQpnwUjIJRMApGARoAAA1IZj5/UTisAAAAAElFTkSuQmCC","orcid":"","institution":"Lebanese American University","correspondingAuthor":true,"prefix":"","firstName":"Sahar","middleName":"","lastName":"Obeid","suffix":""}],"badges":[],"createdAt":"2024-10-29 11:08:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5353747/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5353747/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":69915384,"identity":"ae915926-06d1-474d-b9a9-235099178998","added_by":"auto","created_at":"2024-11-26 14:24:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":123750,"visible":true,"origin":"","legend":"\u003cp\u003eStandardized loading factors of the Shitsu-Taikan-Sho (alexisomia) Scale items in Arabic. DIB = Difficulty in Identifying Bodily Feeling; OA = Overadaptation; LHM = Lack of Health Management. STSS = Shitsu-Taikan-Sho Scale.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5353747/v1/b08ed21a5150b4ac32871bc8.png"},{"id":79432174,"identity":"021ee9b5-9e98-4324-a697-6b2acf62ecdf","added_by":"auto","created_at":"2025-03-28 11:01:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":788795,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5353747/v1/a1124245-9bdd-4d63-be83-24fdca11fc65.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychometric Properties of the Arabic Translation of the Shitsu-Taikan-Sho (alexisomia) Scale (AR-STSS) in adults","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAlexisomia, or \u0026ldquo;no words to describe bodily states\u0026rdquo;, is a \u0026ldquo;clinical concept that refers to the characteristics of having difficulty in awareness and expression of bodily (somatic) emotions or sensations\u0026rdquo; (Ikemi \u0026amp; Ikemi, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e1986\u003c/span\u003e; Kanbara \u0026amp; Fukunaga, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Moriguchi \u0026amp; Komaki, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Oka, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This concept is implied by \"shitsu-taikan sho,\" where \"shitsu\" means deficiency, \"taikan\" denotes somatic emotions and sensations, and \"sho\" indicates a condition or symptom (Oka, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Dr. Yujiro Ikemi, the pioneer of psychosomatic medicine in Japan (Ikemi, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e1979\u003c/span\u003e), first proposed this concept in 1979 based on his observations that patients with psychosomatic diseases struggle with the awareness and expression of not only their emotions, known as alexithymia, but also somatic emotions and sensations, known as alexisomia (Oka, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Oka \u0026amp; Lkhagvasuren, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). There have been suggestions that psychosomatic diseases may develop and persist as a result of alexisomia (Kanbara \u0026amp; Fukunaga, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Oka, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Alexithymia, a personality feature originally recognized by P.E. Sifneos in 1973 and defined by a \"difficulty in identifying, experiencing, and expressing emotions\", has been found to have a significant role in the development of alexisomia in patients with psychosomatic disorders (Sifneos, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e1973\u003c/span\u003e). Ikemi observed in 1977 that in numerous cases of alexithymia, where a difficulty in the awareness and expression of feelings is seen, there have been additionally a difficulty in experiencing awareness and expression of bodily feelings (Oka, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This led to the conclusion that the majority of diseases in the modern world, particularly those affecting adults, are caused by a lack of awareness of one's own body's emotions. Thus, alexisomia places more emphasis on body awareness (interoceptive/proprioceptive), whereas alexithymia places more emphasis on emotions overall (Oka \u0026amp; Lkhagvasuren, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMoreover, alexithymia, depression, anxiety, and stress were all proven to be dimensional phenomena that appear on a continuum within the society (Kotov et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). With alexithymia being moderately to strongly linked with levels of depression and anxiety symptoms in numerous studies (Li et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Marchesi et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2000\u003c/span\u003e; M\u0026uuml;ller et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2003\u003c/span\u003e), alexithymia was also seen as a substantial transdiagnostic risk factor for many issues: substance abuse, eating disorders, anxiety disorders, depression, personality disorders and psychosomatic diseases (Bankier et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; Taylor et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e1999\u003c/span\u003e). However, since alexisomia is a relatively new field of study and not entirely distinct from alexithymia, current research is still in its early stages, with a strong need to explore its correlations and implications.\u003c/p\u003e \u003cp\u003eAs the idea of alexisomia first surfaced, early observational research carried out in Japan revealed that people with psychosomatic problems exhibit characteristics of alexisomia (Oka, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Due to the variability and inconsistency in defining alexisomia and the differences in the measurement techniques across the studies, it became crucial to establish standardized methods for defining and evaluating this emerging clinical concept. Prior to the Shitsu-Taikan-Sho Scale (STSS) being introduced in 2012, there was no dedicated self-report instrument available for alexisomia assessment (Oka, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe Shitsu-Taikan-Sho Scale (STSS)\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe Shitsu-Taikan-Sho Scale (STSS) is a self-administered questionnaire that measures alexisomia. It has 23 items that are assessed on a 5-point Likert scale (Arimura et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Oka, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The STSS is composed of three subscales: Difficulty Identifying Bodily Sensations (DIB), Overadaptation (OA), and Lack of Health Management (LHM) related to bodily feelings (Hasuo et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The DIB subscale addresses a lack of knowledge regarding allostatic stress and homeostasis-related bodily signals, both normal and disordered. The OA subscale tackles the tendency to prioritize social expectations of one's own body experiences. The LHM subscale focuses on the inadequate medical attention to bodily sensations (Arimura et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Oka, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The total score and subscores of the original Japanese Shitsu-Taikan-Sho Scale showed sufficient internal consistency (α\u0026thinsp;=\u0026thinsp;0.70\u0026ndash;0.84) and test-retest reliability (r\u0026thinsp;=\u0026thinsp;0.71\u0026ndash;0.81) in the results (Oka, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The Mongolian version of the Shitsu-Taikan-Sho Scale, consisting of 21 items, showed a Cronbach\u0026rsquo;s alpha value of 0.860, confirming its good internal consistency, and test-retest reliability analysis displayed good reliability (ICC\u0026thinsp;=\u0026thinsp;0.791) (Lkhagvasuren et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Finally, the Turkish version of the Shitsu-Taikan-Sho Scale consisted of 18 items only, with a Cronbach\u0026rsquo;s alpha coefficient ranging from 0.711 to 0.825 (Aksu et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eThe present study\u003c/h3\u003e\n\u003cp\u003eA global transition from communicable to noncommunicable chronic illnesses has occurred in recent decades, with Lebanon - a developing country with a unique cultural background - experiencing this change. Developing nations like Lebanon have been more severely impacted by this shift than developed nations (Bollyky et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Bourne, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Additionally, Lebanon, a low-income country in the Middle East, has been dealing for years with civil unrest, economic collapse, governmental corruption, COVID-19 pandemic, and the deadly 2020 Beirut Blast (El Hajj, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Consequently, this research aims to assess the psychometric properties of the Arabic version of the Shitsu-Taikan-Sho (Alexisomia) Scale in Lebanese adults. The study will provide substantial insight into the validity and reliability of the Arabic version of the STSS, which is essential to establishing treatments to improve the Lebanese population's physical and mental health. The Arabic Shitsu-Taikan-Sho (Alexisomia) Scale (Ar-STSS) is expected to: (1) replicate the three-factor structure that was first proposed; (2) exhibit strong composite validity and invariance of measurements by sex (males vs. females); and (3) show sufficient patterns of correlations with measures of alexithymia, depression and anxiety.\u003c/p\u003e \u003c/div\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eStudy design and sampling\u003c/h2\u003e \u003cp\u003eThis cross-sectional study was performed during April 2024. The snowball sampling method was used to gather data using a shared Google Form link. The research team first contacted acquainted adults, who were subsequently requested to share the link with their friends and relatives within the same age group. Included were adult Lebanese participants above 18 years of age residing in Lebanon. Excluded were individuals who have not finished\u0026nbsp;filling the questionnaire. The survey was anonymous, with participation being completely voluntary and without compensation.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eForward and back translation procedure\u003c/h3\u003e\n\u003cp\u003ePrior to its application in the present study, the Shitsu-Taikan-Sho (alexisomia) Scale was translated in order to make it appropriate for the Arabic language and cultural setting. A single bilingual translator, whose native language is Arabic, carried out the forward translation. A panel of experts examined the translated Arabic version that was obtained. After that, a backward translation was carried out. The back-translated questionnaire was then compared by an expert committee to the original one. Until all ambiguities vanished, the forward-back translation process was repeated. Following international guidelines, the translation attempted to achieve semantic equivalency between the original measures and their Arabic equivalents (Van Widenfelt et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). A pilot study comprising 30 participants was carried out to confirm to ensure that each question was comprehended; no adjustments were made following the pilot research.\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003e \u003cem\u003eThe Shitsu-Taikan-Sho Scale (STSS)\u003c/em\u003e is a self-administered questionnaire that measures alexisomia. It has twenty-three items that are assessed on a 5-point Likert scale, with a total score ranging from 23 to 115 (Arimura et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Oka, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The STSS subscales include a three-dimensional scale: Difficulty Identifying Bodily Sensations (DIB), Overadaptation (OA), and Lack of Health Management (LHM) related to bodily feelings (Hasuo et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The DIB subscale consists of nine questions (items 1, 5, 6, 10, 12, 14, 15, 18, and 19) with an average score of 18.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6 points among college students in Japan, that address a dearth of knowledge on body signals pertaining to homeostasis and allostatic stress, both normal and disordered. The OA subscale consists of six questions (items 3, 7, 13, 17, 20, and 22) with an average score of 14.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5 points, that address the propensity to disregard bodily sensations in order to prioritize social expectations. The LHM subscale, which included seven questions (reverse-scored items 2, 4, 8, 9, 11, 16, and 21, excluding item 23) with an average score of 21.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8 points, focused on the provision of insufficient medical attention in response to bodily sensations (Arimura et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Oka, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The sum of the responses to each of the 23 items determines the final score, while the responses within each subscale are added up to determine the subscale score. Thus, out of 115 total points, the average overall score was 56.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2.\u003c/p\u003e \u003cp\u003e \u003cem\u003eThe Generalized Anxiety Disorder (GAD-5).\u003c/em\u003e Validated in Lebanon (preprint article), the GAD-5 is a 5-item scale evaluating anxiety symptoms experienced in the last 2 weeks (Goldberg et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Goldberg et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Participants evaluate how well each statement described their recent experiences on a 10-point Likert scale (\u0026ldquo;0\u0026thinsp;=\u0026thinsp;does not describe me and 10\u0026thinsp;=\u0026thinsp;describes me exactly). Higher scores indicate higher GAD (ω\u0026thinsp;=\u0026thinsp;.93 / α\u0026thinsp;=\u0026thinsp;.93).\u003c/p\u003e \u003cp\u003e \u003cem\u003ePatient Health Questionnaire (PHQ-9).\u003c/em\u003e The PHQ-9, a nine-item self-report measure validated in Arabic (Sawaya et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), is used to measure and track the severity of depression. As a severity measure, the PHQ-9 score can range from 0 to 27, since each of the 9 items can be scored from 0 (not at all) to 3 (nearly every day). An item was also added to the end of the diagnostic portion of the PHQ-9 asking patients who checked off any problems on the questionnaire: \u0026ldquo;How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?\u0026rdquo;. Higher scores indicate higher level of depression (ω\u0026thinsp;=\u0026thinsp;.89 / α\u0026thinsp;=\u0026thinsp;.89).\u003c/p\u003e \u003cp\u003e \u003cem\u003eToronto Alexithymia Scale (TAS-20).\u003c/em\u003e The Toronto Alexithymia Scale (TAS-20), validated in Arabic (El Frenn et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), is an alexithymia measurement tool with 20 items developed by Bagby et al. (Bagby et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e1994\u003c/span\u003e). Twenty statements on the scale, ranked from 1 to 5 using 5-point Likert scale, represent an individual's incapacity to recognize and characterize their feelings and divided into three subscales to assess three dimensions: Difficulty Identifying Feelings (DIF) subscale, Difficulty Describing Feelings (DDF) subscale, and Externally-Oriented Thinking (EOT) subscale. TAS-20 scores have a cut-off of 51 for non-alexithymia, 52\u0026ndash;60 for potential alexithymia, and 61 or higher for alexithymia.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eAnalytic Strategy\u003c/h2\u003e \u003cp\u003eThe dataset had no missing responses. Using SPSS AMOS version 29, a Confirmatory Factor Analysis (CFA) was conducted on the complete sample data. The computed minimum sample size varied from 69 to 460 participants, providing sufficient statistical power for the CFA, based on whether the sample had 3 to 20 times the number of variables in the scale (Mundfrom et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). The parameter estimations were obtained using the maximum likelihood technique. The normed chi-square (χ\u0026sup2;/df), the Standardized Root Mean Square Residual (SRMR), the Tucker-Lewis Index (TLI), the Steiger-Lind Root Mean Square Error of Approximation (RMSEA), and the Comparative Fit Index (CFI) were among the fit indices that were calculated. Adequate values were \u0026le;\u0026thinsp;5 for χ\u0026sup2;/df, \u0026le; .08 for RMSEA, \u0026le; .05 for SRMR and .90 for CFI and TLI (Hu \u0026amp; Bentler, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1999\u003c/span\u003e). Items with loading factors less than 0.33 were eliminated. Following the initial failure to prove multivariate normality (Bollen-Stine bootstrap p\u0026thinsp;=\u0026thinsp;.002), we used a non-parametric bootstrapping technique.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSex invariance\u003c/h2\u003e \u003cp\u003eSex invariance of STSS scores was evaluated by a multi-group CFA with the total sample (Chen, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). Three layers of measurement invariance testing were conducted: configural, metric, and scalar (Vandenberg \u0026amp; Lance, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). We considered ΔCFI\u0026thinsp;\u0026le;\u0026thinsp;.010, ΔRMSEA\u0026thinsp;\u0026le;\u0026thinsp;.015, or ΔSRMR\u0026thinsp;\u0026le;\u0026thinsp;.010 (with a ΔSRMR threshold of .030 for factorial invariance) as indicators of invariance (Fekih-Romdhane et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). McDonald's ω and Cronbach's α were used to assess composite reliability; values greater than .70 indicated adequate composite reliability (Dunn et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Normality was confirmed because the skewness and kurtosis values for each item on the scale ranged from \u0026minus;\u0026thinsp;1 to +\u0026thinsp;1 (Hair Jr et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The Student's t-test was employed to compare two means, and the Pearson test was conducted to evaluate the association between STSS scores and other scales.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eA total of 758 participants \u0026minus;\u0026thinsp;61.2% of whom were female - completed the survey; their average age was 30.27\u0026thinsp;\u0026plusmn;\u0026thinsp;13.80 years [range: 18 to 90]. Additionally, the average Household Crowding Index (HCI) was 1.23\u0026thinsp;\u0026plusmn;\u0026thinsp;.57 individuals per room, and 74.5% of the population held a university degree.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eConfirmatory Factor Analyses\u003c/h2\u003e \u003cp\u003eAccording to CFA, the initial model's fit (Oka, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) was poor: χ\u003csup\u003e2\u003c/sup\u003e/df\u0026thinsp;=\u0026thinsp;1266.51/227\u0026thinsp;=\u0026thinsp;5.58, RMSEA\u0026thinsp;=\u0026thinsp;.099 (90% CI .094, .104), SRMR\u0026thinsp;=\u0026thinsp;.114, CFI\u0026thinsp;=\u0026thinsp;.748, TLI\u0026thinsp;=\u0026thinsp;.719.\u003c/p\u003e \u003cp\u003eThe Mongolian model's CFA (Lkhagvasuren et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) was relatively modest: χ\u003csup\u003e2\u003c/sup\u003e/df\u0026thinsp;=\u0026thinsp;467.21/87\u0026thinsp;=\u0026thinsp;5.37, RMSEA\u0026thinsp;=\u0026thinsp;.097 (90% CI .088, .106), SRMR\u0026thinsp;=\u0026thinsp;.067, CFI\u0026thinsp;=\u0026thinsp;.845, TLI\u0026thinsp;=\u0026thinsp;.812.\u003c/p\u003e \u003cp\u003eThe Turkish model's CFA (Aksu et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) indicated a better fit: χ\u003csup\u003e2\u003c/sup\u003e/df\u0026thinsp;=\u0026thinsp;474.70/132\u0026thinsp;=\u0026thinsp;3.60, RMSEA\u0026thinsp;=\u0026thinsp;.075 (90% CI .067, .082), SRMR\u0026thinsp;=\u0026thinsp;.071, CFI\u0026thinsp;=\u0026thinsp;.886, TLI\u0026thinsp;=\u0026thinsp;.867. The second-order model's fit indices were good: χ\u003csup\u003e2\u003c/sup\u003e/df\u0026thinsp;=\u0026thinsp;474.70/132\u0026thinsp;=\u0026thinsp;3.60, RMSEA\u0026thinsp;=\u0026thinsp;.075 (90% CI .067, .082), SRMR\u0026thinsp;=\u0026thinsp;.071, CFI\u0026thinsp;=\u0026thinsp;.886, TLI\u0026thinsp;=\u0026thinsp;.867. All of the standardized factor loading estimations were sufficient (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). For the entire sample, the composite reliability of the scores was adequate (ω\u0026thinsp;=\u0026thinsp;.89 / α\u0026thinsp;=\u0026thinsp;.89).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSex Invariance\u003c/h2\u003e \u003cp\u003eAt the configural, metric, and scalar levels, we were able to demonstrate the invariance across sex (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). No significant difference was observed between females and males in terms of alexisomia (53.19\u0026thinsp;\u0026plusmn;\u0026thinsp;13.58 vs 52.28\u0026thinsp;\u0026plusmn;\u0026thinsp;11.93; \u003cem\u003et\u003c/em\u003e(465)\u0026thinsp;=\u0026thinsp;.76; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.450).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eMeasurement Invariance of the Shitsu-Taikan-Sho (alexisomia) Scale across Sex in the total sample.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCFI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRMSEA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSRMR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModel Comparison\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eΔCFI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eΔRMSEA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eΔSRMR\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConfigural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.874\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.087\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetric\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.872\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.094\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eConfigural vs metric\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScalar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.863\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.094\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMetric vs scalar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003cem\u003eNote.\u003c/em\u003e CFI\u0026thinsp;=\u0026thinsp;Comparative fit index; RMSEA\u0026thinsp;=\u0026thinsp;Steiger-Lind root mean square error of approximation; SRMR\u0026thinsp;=\u0026thinsp;Standardised root mean square residual.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eConcurrent validity\u003c/h2\u003e \u003cp\u003eHigher alexisomia scores were significantly associated with higher alexithymia (r\u0026thinsp;=\u0026thinsp;.50; p\u0026thinsp;\u0026lt;\u0026thinsp;.001), depression (r\u0026thinsp;=\u0026thinsp;.37; p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and anxiety (r\u0026thinsp;=\u0026thinsp;.26; p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAccording to the current study, the Arabic version of the STSS is adequate to be used for the assessment of alexisomia in the Lebanese population, through its good factor structure,adequate reliability and validity. Moreover, it can be used for the assessment of alexisomia in both genders.\u003c/p\u003e \u003cp\u003eA composite reliability of .89 was found for the Arabic STSS total score, which reflects a high level of internal consistency and the consistency of the measurement's results. The Cronbach\u0026rsquo;s alpha coefficient was between 0.70 and 0.84 for the original Japanese version (Oka, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), 0.860 for the Mongolian version (Lkhagvasuren et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), and 0.825 for the Turkish version (Aksu et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Thus, with a higher internal consistency between the previously validated versions of Shitsu-Taikan-Sho Scale, the Arabic version of the STSS is reliably capturing the same underlying concept, making the results from this tool trustworthy and stable.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eFactor structure\u003c/h2\u003e \u003cp\u003eAccording to CFA, the initial model's fit was poor (Oka, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In our study, the high χ\u0026sup2;/df ratio (=\u0026thinsp;5.58) with values greater than 3 showing a poor fit, elevated RMSEA (=\u0026thinsp;.099) just below the standard threshold of .10, high SRMR (=\u0026thinsp;.114) above the accepted threshold of .08, and low CFI (=\u0026thinsp;.748) and TLI (=\u0026thinsp;.719) below the recommended threshold of .90, all indicate that the model does not adequately represent the data. This implies that in order to improve the model's fit to the data, it may need to be modified and revised by re-evaluating the model structure, adding or removing factors, or considering alternative models. Moreover, the Mongolian model's CFA (Lkhagvasuren et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) in the present study was relatively modest with some indices suggesting the fit could be improved. While the SRMR is acceptable, the χ\u0026sup2;/df ratio, RMSEA, CFI, and TLI suggest that the model may not be an ideal fit and may require modifications or enhancements to better align with the data. This might be explained by the differences between Lebanese, Japanese, and Mongolian populations in terms of an assortment of cultural, historical, socioeconomic, and demographic characteristics as well as their perceptions of mental health between the Middle East and the Far East. This can be explained by the absence of Far East historical relics in the Middle East, and its recent pursuit to implement soft power through language acquisition, traditional sports, cultural promotion, and exchange (Choudhury, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). These elements collectively shape how individuals from each population perceive and communicate psychological phenomena.\u003c/p\u003e \u003cp\u003eConversely, the Turkish model's CFA (Aksu et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) indicated a better fit compared to the Mongolian and original model in our current research. The Turkish model fits the data more reasonably, according to the χ\u0026sup2;/df ratio, RMSEA, and SRMR, although the CFI and TLI are slightly below the ideal threshold but still point to an overall good fit. Lebanese linguistic and communication facets may be more closely aligned with the Turkish model. Turkish and Arabic are close to each other in the global linguistic realm. These languages have entwined histories, changing throughout time and having geographic links to language use. Additionally, Turkish and Arabic (the official language of Lebanon) have some linguistic/cultural commonalities that might influence how emotional expressions are perceived and assessed. The common features in societal norms and practices between Turkey and Lebanon comes from their religious, economic, and social characteristics (Kalafatoglu \u0026amp; Mendoza, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), making the Turkish model more contextually relevant in our study. In contrast, Mongolian cultural practices and values are quite different, which might cause scale items to be misinterpreted. Therefore, the Turkish model may be less effective in capturing alexisomia compared to the Mongolian and original version, since the social structures in Lebanon may be more similar to those in Turkey in terms of family dynamics and societal roles.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSex invariance\u003c/h2\u003e \u003cp\u003eSex disparities in the reporting of somatic symptoms have been shown in a number of research conducted in various contexts (Nakao et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). However, at the configural, metric, and scalar levels, we were able to demonstrate the invariance across sex. No discernible difference in alexisomia was observed between the sexes, in line with previous studies (Gan et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Lkhagvasuren et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Oka \u0026amp; Lkhagvasuren, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Men and women may perceive and process emotions similarly (Fischer et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), resulting in analogous levels of alexisomia. Indeed, there may not be significant gender differences in alexisomia since males and females may have similar biological sensitivity to emotional and bodily stimuli (Carvalho et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Codispoti et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Hillman et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). Moreover, psychological factors similarly prominent in both genders may also have an impact on alexisomia.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eConcurrent validity\u003c/h2\u003e \u003cp\u003eOur findings showed that higher alexisomia is associated with higher alexithymia. Emotional awareness and somatic interoceptive awareness are vital for humans\u0026rsquo; psychosomatic health (Kanbara \u0026amp; Fukunaga, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). One prevalent trait linked to a lack of emotional awareness in relation to psychosomatic illnesses is alexithymia. Conversely, alexisomia refers to the lack of somatic awareness. As we know, a strong connection exists between the body and emotions, particularly, the more subtle an emotion is, the more marked its effects on the body. Additionally, a decline in emotional awareness is linked with a reduced sensitivity to bodily sensations, explaining why somatic awareness is essential for emotional awareness (Kanbara \u0026amp; Fukunaga, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Consequently, the \"body\" and the \"mind\" are essentially two facets of the same entity (Kanbara \u0026amp; Fukunaga, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). As a result, alexithymia and alexisomia have significant overlap and are not completely divergent. Two studies suggest that alexisomia is strongly linked to alexithymia (Ikemi \u0026amp; Ikemi, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e1986\u003c/span\u003e; Oka, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). There is a growing body of research on alexisomia and its relationship to alexithymia(Kanbara \u0026amp; Fukunaga, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Ikemi acknowledged, \u0026ldquo;in many cases of alexithymia, where there is an observed difficulty in the awareness and expression of feelings, there also seems to be a difficulty in the awareness and expression of bodily feelings\u0026rdquo; and saw characteristics of both alexithymia and alexisomia in people suffering from psychosomatic illnesses (Ikemi \u0026amp; Ikemi, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e1986\u003c/span\u003e). According to Oka, alexisomia is an extension of alexithymia (Oka, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). By looking at neuroimaging studies, Moriguchi and Komaki investigated the connection between alexithymia and alexisomia (Moriguchi \u0026amp; Komaki, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Since bodily states act as a context for emotions, shaping affective processes in a manner similar to the effects of external contexts and occasion setters (Pearce \u0026amp; Bouton, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2001\u003c/span\u003e), they concluded that somatic awareness is the foundation of emotional awareness (Kanbara \u0026amp; Fukunaga, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, greater alexisomia scores were substantially associated with higher levels of anxiety and depression. The amount of literature on alexisomia is quite modest, given that it is an emerging topic. To our knowledge, this study is the first to address the association between three major psychological concerns; alexisomia, depression and anxiety. Individuals with high alexisomia often \u0026ldquo;have difficulties in expressing how their bodies feel\u0026rdquo; (Ikemi \u0026amp; Ikemi, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e1986\u003c/span\u003e), which thus lead to poor emotional regulation as proven by the connection between the alexisomia subscale OA and emotional regulation (Aksu et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). This can lead to elevated levels of stress and anxiety, as individuals may find it difficult to properly control their emotions. As proven by the stress-alexithymia hypothesis, \u0026ldquo;lacking emotional awareness leads to ineffective coping, which prolongs the exposure to stressors and predisposes to mental health problems\u0026rdquo; (Martin \u0026amp; Pihl, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e1985\u003c/span\u003e). Therefore, they may be more sensitive to stressors, having a hard time coping with them, exacerbating by then the anxiety and depression, supported by multiple studies (Dong et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Spada et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Until now, studies on alexisomia and its connections to other psychological factors have not been sufficiently conducted. Future research is recommended in order to understand in depth the correlation between alexisomia and mental health.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eClinical Implications\u003c/h2\u003e \u003cp\u003eValidating and assessing the psychometric properties of the STSS in an Arab-speaking society within a developing Middle Eastern nation is a major contribution to the field. As the Arabic STSS provides an accurate assessment of alexisomia, it can be highly useful in clinical settings. By using it, medical professionals can gain a deeper understanding of patients' challenges in recognizing and expressing their bodily emotions, important for precise diagnosis and efficient treatment planning. Thus, improving overall quality of care and enabling better patient outcomes by providing a detailed insight of the patient's emotional experience.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eSome limitations should be acknowledged and addressed in future research. Information bias might have occurred if patients misinterpreted the questions or over/underestimated the responses. Response bias may be introduced by using self-report measures and convenience web-based sampling methods, thus affecting the representativeness of the study's sample. In addition, only a general population sample was included in the present study. We suggest conducting further investigation on the psychometric properties of the Arabic STSS in clinical populations with the inclusion of control groups in order to make accurate conclusions regarding individuals with alexisomia. The inclusion of Arabic-speaking adults from only one Arab nation\u0026mdash;Lebanon\u0026mdash;is another drawback. Although Arab countries share some social, religious, and cultural similarities (Makhlouf Obermeyer, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Sewilam et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), significant variances do exist, emphasizing the necessity for further cross-cultural validation of the Ar-STSS in other regional contexts.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eOur contribution to the corpus of existing literature is to deepen our comprehension of the STSS's psychometric qualities in an unusual context and language. Since language limitations are a major hindrance to appropriate medical communication and management, translation of the STSS to Arabic and validation of its psychometric properties was essential. The linguistically validated Arabic version of the STSS can be used to screen for alexisomia among Lebanese adults. To validate our findings and extend the use of the Arabic versions of this scale, further research is needed in additional Arabic-speaking nations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e: The Lebanese International University\u0026apos;s School of Pharmacy ethics committee granted this study ethics permission (2024ERC-042-LIUSOP).\u0026nbsp;A written informed consent was obtained from each participant when completing the online form. All methods were performed in accordance with the relevant guidelines and regulations (in accordance with the Declaration of Helsinki).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe data that support the findings of this study are available from the corresponding author but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the ethics committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors have nothing to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u0026nbsp;\u003c/strong\u003eF.F.R, S.O and S.H designed the study; D.M, F.S and M.D collected the data, S.S drafted the manuscript; S.H carried out the analysis and interpreted the results; all authors reviewed the final manuscript and gave their consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eThe authors would like to thank all participants.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAksu MH, Baltacı NN, Ertek İE, Coşar B. 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Effects of practicing yoga on alexisomia: an open-label trial. Biopsychosoc Med. 2022;16(1):14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePearce JM, Bouton ME. Theories of associative learning in animals. Ann Rev Psychol. 2001;52(1):111\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSawaya H, Atoui M, Hamadeh A, Zeinoun P, Nahas Z. Adaptation and initial validation of the Patient Health Questionnaire\u0026ndash;9 (PHQ-9) and the Generalized Anxiety Disorder\u0026ndash;7 Questionnaire (GAD-7) in an Arabic speaking Lebanese psychiatric outpatient sample. Psychiatry Res. 2016;239:245\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSewilam AM, Watson AM, Kassem AM, Clifton S, McDonald MC, Lipski R, Deshpande S, Mansour H, Nimgaonkar VL. Suggested avenues to reduce the stigma of mental illness in the Middle East. Int J Soc Psychiatry. 2015;61(2):111\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSifneos PE. The prevalence of \u0026lsquo;alexithymic\u0026rsquo;characteristics in psychosomatic patients. Psychother Psychosom. 1973;22(2\u0026ndash;6):255\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpada MM, Nikčević AV, Moneta GB, Wells A. Metacognition, perceived stress, and negative emotion. Pers Indiv Differ. 2008;44(5):1172\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaylor GJ, Bagby RM, Parker JD. Disorders of affect regulation: Alexithymia in medical and psychiatric illness. Cambridge University Press; 1999.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Widenfelt BM, Treffers PD, De Beurs E, Siebelink BM, Koudijs E. Translation and cross-cultural adaptation of assessment instruments used in psychological research with children and families. Clin Child Fam Psychol Rev. 2005;8:135\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVandenberg RJ, Lance CE. A review and synthesis of the measurement invariance literature: Suggestions, practices, and recommendations for organizational research. Organizational Res methods. 2000;3(1):4\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Shitsu-Taikan-Sho (Alexisomia) Scale, Psychometric properties, Arabic","lastPublishedDoi":"10.21203/rs.3.rs-5353747/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5353747/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eOur aim in this study is to assess the psychometric properties of the Arabic version of the Shitsu-Taikan-Sho (Alexisomia) Scale (Ar-STSS) in a sample of Lebanese adults.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData for this cross-sectional study was gathered using a Google form link. A sample of 758 Lebanese adults (61.2% females, mean age of 30.27\u0026thinsp;\u0026plusmn;\u0026thinsp;13.80 years) completed an online questionnaire.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAccording to CFA, the initial model's fit was poor: χ\u003csup\u003e2\u003c/sup\u003e/df\u0026thinsp;=\u0026thinsp;1266.51/227\u0026thinsp;=\u0026thinsp;5.58, RMSEA\u0026thinsp;=\u0026thinsp;.099 (90% CI .094, .104), SRMR\u0026thinsp;=\u0026thinsp;.114, CFI\u0026thinsp;=\u0026thinsp;.748, TLI\u0026thinsp;=\u0026thinsp;.719. The Turkish model's CFA indicated a better fit: χ\u003csup\u003e2\u003c/sup\u003e/df\u0026thinsp;=\u0026thinsp;474.70/132\u0026thinsp;=\u0026thinsp;3.60, RMSEA\u0026thinsp;=\u0026thinsp;.075 (90% CI .067, .082), SRMR\u0026thinsp;=\u0026thinsp;.071, CFI\u0026thinsp;=\u0026thinsp;.886, TLI\u0026thinsp;=\u0026thinsp;.867. The second-order model's fit indices were good: χ\u003csup\u003e2\u003c/sup\u003e/df\u0026thinsp;=\u0026thinsp;474.70/132\u0026thinsp;=\u0026thinsp;3.60, RMSEA\u0026thinsp;=\u0026thinsp;.075 (90% CI .067, .082), SRMR\u0026thinsp;=\u0026thinsp;.071, CFI\u0026thinsp;=\u0026thinsp;.886, TLI\u0026thinsp;=\u0026thinsp;.867. The composite reliability of the scores was adequate (ω\u0026thinsp;=\u0026thinsp;.89). No significant difference was observed between sex in terms of alexisomia (53.19\u0026thinsp;\u0026plusmn;\u0026thinsp;13.58 vs 52.28\u0026thinsp;\u0026plusmn;\u0026thinsp;11.93; \u003cem\u003et\u003c/em\u003e(465)\u0026thinsp;=\u0026thinsp;.76; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.450). Higher alexisomia were significantly associated with higher alexithymia (r\u0026thinsp;=\u0026thinsp;.50; p\u0026thinsp;\u0026lt;\u0026thinsp;.001), depression (r\u0026thinsp;=\u0026thinsp;.37; p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and anxiety (r\u0026thinsp;=\u0026thinsp;.26; p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe linguistically validated Arabic version of the Shitsu-Taikan-Sho (Alexisomia) Scale can be used to screen for alexisomia among Lebanese adults.\u003c/p\u003e","manuscriptTitle":"Psychometric Properties of the Arabic Translation of the Shitsu-Taikan-Sho (alexisomia) Scale (AR-STSS) in adults","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-26 14:23:54","doi":"10.21203/rs.3.rs-5353747/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a8beca5a-b9d4-406e-836c-792e0f7890a3","owner":[],"postedDate":"November 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-14T23:01:45+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-26 14:23:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5353747","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5353747","identity":"rs-5353747","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}