Validation of an electronic version of the Self‐Awareness Questionnaire in English and Italian healthy samples

Abstract

Objectives

Interoception is a general sensitivity to bodily sensations that informs motivational processes and behaviours. Interoceptive abilities seem to be impaired in several clinical conditions, and the development of new pragmatic instruments to assess subjective components of interoception are crucially needed. An easy to use paper and pencil questionnaire measuring sensitivity to bodily sensations was validated in an Italian sample (Self‐Awareness Questionnaire; SAQ).

Methods

In the present study, we created and evaluated an electronic version of the SAQ in Italian and English language.

Results

Psychometric properties of both electronic versions of the SAQ were validated in an Italian (n = 206) and an English (n = 275) sample, using factorial analyses. Differences in factorial structures observed between the two samples were discussed in terms of cultural impact on emotional regulation and bodily sensations processing.

Conclusions

The electronic version of SAQ in English and Italian provides a pragmatic and validated tool to evaluate bodily signal sensitivity in clinical settings, informing the development of a new therapy targeting interoceptive processes, in a wide range of psychopathological conditions.

1. INTRODUCTION

Interoception is the basic function that gathers proper body sensations, in particular internal feelings such as itch, temperature, pain, visceral sensations, hunger, and heartbeat. This enables the evaluation of the sense of self and allows the maintenance of homeostasis. All bodily information contributes to awareness about proper bodily states and allows us to know “how do you feel now” (Craig, 2003). Several studies have investigated interoception, its components (Terasawa, Moriguchi, Tochizawa, & Umeda, 2014), and its relationships with psychological domains such as emotions and mood (Critchley, Wiens, Rothstein, Ohlamn, & Dolan, 2004; Pollatos, Herbert, Matthias, & Shandry, 2007). Particularly, interoceptive processes seem to be strongly linked with anxiety. Because anxiety is a psychological condition that manifests itself through many somatic correlates, it is plausible to consider a vicious circle in which interoceptive processes affect and maybe even cause anxiety (especially when physical sensations are misinterpreted). And anxiety, in turn, intensifies somatic perception and complaints, making the subject more aware of bodily signals (Marcus, Gurley, Marchi, & Bauer, 2007; Mumford et al., 1991; Paulus & Stein, 2010).

Similarly, an emergent theory suggests that alexithymia, a personality construct characterized by difficulties identifying emotional feelings, is in fact the outcome of an interoceptive failure (Betka et al., 2017; Bornemann & Singer, 2017; Brewer, Cook, & Bird, 2016; Murphy, Catmur, & Bird, 2017; Shah, Hall, Catmur, & Bird, 2016). The mutual interaction between interoception and emotion has been repeatedly confirmed by neuroscientific studies; good interoceptive abilities are associated with stable body representations, greater emotional theory of mind processing, greater sensitivity to emotion, and increased recognition of emotional facial expressions (Ferguson & Katkin, 1996; Shah et al., 2016; Tsakiris, Tajadura‐Jimenez, & Costantini, 2011; Wiens, Mezzacappa, & Katkin, 2000).

Interoception is composed of three factors: sensitivity, measured by the heartbeat perception (Shandry, 1981); awareness, referring to the cognitive appreciation of interoceptive stimuli; and sensibility as the proper tendency to focus on internal states, subject to individual variability (Jones, 1994). Usually, both sensibility and awareness are well assessed by self‐report measures (Terasawa, Shibata, Moriguchi, & Umeda, 2013).

To date, most studies have focused on interoceptive sensitivity, measured using objective measures such as heartbeat counting (Ferentzi, Drew, Tihanyi, & Köteles, 2018; Garfinkel, Seth, Barrett, Suzuki, & Critchley, 2015; Marshall et al., 2017; Shandry, 1981). Despite the increasing interest in bodily awareness processes, only a few studies have developed new assessment tools to subjectively assess these processes. These questionnaires often include bodily awareness as a subscale within a broader context of body investigation, an example being the Body Perception Questionnaire, (Porges, 1993), and are often complex and timely to complete such as the multidimensional assessment of interoceptive awareness (Mehling et al., 2012).

A more recent novel self‐report instrument was created called the Self‐Awareness Questionnaire (SAQ; Longarzo et al., 2015). This simple and easy to use instrument assesses the experience and frequency of inner bodily sensations and was developed using a large sample of Italian participants. The SAQ revealed a bifactorial structure useful in evaluating both somatosensory and visceral sensations and has demonstrated good psychometric properties. The SAQ has been shown to be a valid measure of sensitivity to bodily sensations in two clinical populations: patients with illness anxiety disorder (Grossi et al., 2017) and patients with irritable bowel syndrome (Longarzo et al., 2016), in which bodily sensation awareness was correlated with structural and functional brain connectivity. However, the SAQ requires additional assessment to further evaluate the properties of the instrument and provide additional evidence of its reliability and validity.

In the present study, the objectives were to present further data to support the validity of the psychometric properties of the SAQ in an Italian sample and to validate an English version of the SAQ in an English sample. In addition, the use of questionnaires can be enhanced by providing alternative formats to paper and pencil instruments. Therefore, in this study, an electronic version of the SAQ in Italian and English was created and was called SAQ because it is an existing instrument.

2. METHODS

2.1. Participants and setting

Two samples were recruited: a British and an Italian sample. Participants were recruited through social media networks (e.g., Facebook), via online advertisements, and poster displays. Participants were native English or Italian speakers, over 16 years of age, with no self‐reported current or historical psychiatric illnesses, or use of psychoactive medications.

A total of 275 healthy native English speakers and 206 healthy native Italian speakers completed the survey. The study was approved by the local research ethics committees. Participation was encouraged with a prize draw to win a £20 prize for the British sample; participants of the Italian sample did not receive any reward.

2.2. Measures and procedure

This study used an online data collection platform (Qualtrics, Provo, UT); this platform electronically displays questionnaires and records participant responses. An Italian version and an English version were created to collect data from each of the samples. Participants were invited to take part in the study through study advertisements. Potential participants were given a link to the online platform that provided information about the study and what would be expected of them. Participants consented by agreeing to the first statement of the survey and clicking continue. The platform did not allow block randomizations; therefore, all participants completed the following measures in the same order.

2.2.1. Socio‐demographic information

This section collected information including age, gender, and education level; several open questions investigated presence of current and previous psychiatric and psychological disorders and current and previous use of psychoactive drugs only for the purpose of excluding participants not fulfilling selection criteria.

2.2.2. Anxiety Sensitivity Index‐3

The Anxiety Sensitivity Index‐3 (ASI‐3; Taylor et al., 2007) is an 18‐item instrument that measures individual differences in anxiety sensitivity. It is composed of three subscales measuring “physical concerns,” “cognitive concerns,” and “social concerns.” The ASI‐3 contains statements such as “It scares me when I am unable to keep my mind on a task” and “When I feel pain in my chest, I worry that I'm going to have a heart attack.” Participants rate their agreement of each statement using a 5‐point scale from Not at all true to Extremely true (0 = Not at all true; 1 = Slightly true; 2 = Moderately true; 3 = Very true; 4 = Extremely true). The total ASI‐3 score is the sum of the responses with a score range between 0 and 72. Higher scores indicate higher levels of anxiety sensitivity.

In English, the ASI‐3 has been shown to have acceptable internal consistency for the three subscales for a healthy population (Cronbach's α 0.79, 0.83, and 0.78, respectively) and good internal consistency for a clinical population (Cronbach's α 0.86, 0.91, and 0.86, respectively). In Italian, the ASI‐3 has shown good internal consistency in a healthy population (Cronbach's α 0.87, 0.83, and 0.81, respectively) and a clinical population (Cronbach's α 0.92, 0.90, and 0.86, respectively; Petrocchi, Tenore, Couyoumdjian, & Gragnani, 2014).

2.2.3. Toronto Alexithymia Scale (Bagby, Parker, & Taylor, 1994)

The Toronto Alexithymia Scale (TAS‐20) is a 20‐item instrument for measuring alexithymia. It consists of three subscales measuring “difficulties identifying feelings,” “difficulties in describing feelings,” and “externally oriented thoughts.” Participants rate each item on a 5‐point Likert scale (from 1 strongly disagree to 5 strongly agree). The total alexithymia score is the sum of the responses of all 20 items providing a score range of 20 and 100. Higher scores indicate higher levels of alexithymia.

The English version of the TAS‐20 has shown good internal consistency for both healthy and clinical populations (Cronbach's α 0.80 and 0.83, respectively). The Italian version has demonstrated good test–retest reliability (0.86) and acceptable internal consistency (Cronbach's α: 0.75) in a wide sample of healthy adults and of medical and psychiatric outpatients (Bressi et al., 1996).

2.2.4. Body Perception Questionnaire Short Form (Porges, 1993)

The Body Perception Questionnaire (BPQ) measures individual differences in sensitivity to bodily sensations. The BPQ measures two subscales of “body awareness” (BPQ_AW) and “awareness and autonomic nervous system reactivity” (BPQ_AU). The BPQ_AW has 26 statements about different bodily sensations (e.g., stomach and gut pains, urge to defecate, and urge to urinate). The BPQ_AU has 20 statements about the autonomic nervous system (e.g., “my heart often beats irregularly” and “I gag from the saliva in my mouth”). For both subscales, participants indicated their awareness of each sensation/statements using a 5‐point scale ranging from never to always (1 = never; 2 = sometimes; 3 = often; 4 = very often; 5 = always). The awareness subscale score is the sum of the responses providing a score ranging from 26 and 130. The autonomic nervous system reactivity subscale score is the sum of the responses providing a score ranging from 20 to 100. Higher scores indicate higher levels of sensitivity to bodily sensations. Although BPQ is a widely used instrument, its English version has not been validated yet, whereas an Italian version has been developed by the authors and reviewed by both English and English‐Italian speakers in order to resolve linguistic inconsistencies.

2.2.5. Self‐Awareness Questionnaire (Longarzo et al., 2015)

The SAQ is a recently developed Italian instrument for measuring bodily sensation self‐awareness (e.g., how frequently signals from the body are felt by respondents). It is composed of 28 statements of bodily sensations; participants rate how often they experience each statement using a 5‐point scale ranging from never to always (1 = never; 2 = sometimes; 3 = often; 4 = very often; 5 = always). The total SAQ score is the sum of the responses of all 28 items providing a score range of 28 to 140 with higher scores indicating higher levels of self‐ awareness related to bodily sensations.

The SAQ has a two‐factor structure of visceral sensations and somatosensory sensations accounting for 29% of the total variation.

This study used an Italian and English version of the SAQ. For the translation into English, a native English speaker and Italian bilingual professor in Psychology carried out the translation from Italian to English. The SAQ English version was reviewed by both English and English‐Italian speakers in order to resolve linguistic inconsistencies.

2.3. Statistical analyses

The following analyses were carried out for both the English and Italian samples.

2.3.1. Descriptive statistics

Descriptive scores for all scales for the English and Italian samples are presented. Differences between scores for the two samples were calculated using independent samples t tests.

2.3.2. Data quality and acceptability

Missing data and floor and ceiling effects were assessed for the SAQ and other instruments. The criterion for data quality and acceptability was <5% missing data and floor and ceiling effects <10%.

2.3.3. Internal consistency reliability

Internal consistency reliability is a measure based on the correlations between different items on a test. It measures whether several items that propose to measure the same general construct produce similar scores. Internal consistency of the SAQ was assessed using Cronbach's alpha. Cronbach's alpha coefficients were calculated for the full scale and each factor. Cronbach's α of ≥0.70 is considered acceptable for internal consistency analysis (Nunnally & Bernstein, 1994).

2.3.4. Factor analysis

Factor analysis using principal axis factoring was carried out to evaluate the factor structure of the SAQ.

The Kaiser–Meyer–Olkin measure of sampling adequacy and Bartlett's test of sphericity were used to check data suitability for factor analysis. Values of Kaiser–Meyer–Olkin greater than 0.70 have been characterized as acceptable. Bartlett's test of sphericity tests the null hypothesis that the correlation matrix is an identity matrix (i.e., that there is no relationship between the items; Pett, Lackey, & Sullivan, 2003). Components explaining an amount of variance greater than a single item (i.e., with eigenvalues >1) were extracted (Kaiser, 1960). We computed factor loadings after oblimin rotation, allowing factors to correlate.

2.3.5. Construct validity

To evaluate the construct validity of the SAQ, Spearman correlations were obtained between the SAQ (full scale and each factor) and the TAS‐20, ASI‐3, BPQ, and their subscales.

3. RESULTS

3.1. Descriptive statistics and sample differences

Participant demographics of the English and Italian samples are presented in Table 1. A one‐way analysis of variance showed no significant differences between the samples for age. Chi‐square analysis found a significant difference between the samples for occupational status but not for gender.

Table 1.

Participant demographics and differences between samples

		English sample (N = 275)	Italian sample (N = 206)	ANOVA/chi‐square
Characteristic		N (%) or mean ± SD (range)		(p value)
Age		30.95 ± 14.16 (18–72)	29.62 ± 9.37 (18–71)	0.243
Gender	Male	70 (25.5)	67 (32.5)	0.089
	Female	205 (74.5)	139 (67.5)
Occupational status	Student	140 (51.7)	73 (35.6)	0.02*
	Professional	104 (38.4)	105 (51.2)
	Other	27 (10)	27 (13.2)

Note. ANOVA: analysis of variance.

^* ≤0.05.

Differences between the two samples showed statistically significant differences for the TAS‐20 total score and all its subscales, for the BPQ_AU subscale of the BPQ, and for the ASI‐3 total score and subscales cognitive concerns and social concerns. Means and standard deviations of all scales for each sample are shown in Table 2.

Table 2.

Mean questionnaire scores for UK and Italian samples and differences between samples

		English sample (N = 275)	Italian sample (N = 206)	t test
Measure	Type	N (%) or mean ± SD (range)		(p value)
TAS‐20	Total score	48.67 ± 11.94 (26–86)	43.59 ± 11.04 (20–80)	<0.001**
	DIF	16.52 ± 6.16 (7–33)	15.01 ± 5.87 (7–32)	0.011*
	DDF	13.35 ± 4.82 (5–25)	12.40 ± 4.36 (5–24)	0.036*
	EOT	18.80 ± 4.17 (10–30)	16.19 ± 4.29 (8–27)	<0.001**
BPQ	BPQ_AW	2.36 ± 0.84 (1–5)	2.28 ± 0.67 (1.04–4.42)	0.271
	BPQ_AU	1.49 ± 0.43 (1–3.2)	1.61 ± 0.39 (1–2.95)	0.003*
ASI‐3	Total score	17.96 ± 12.23 (0–64)	13.14 ± 8.62 (0–46)	<0.001**
	Physical concerns	5.24 ± 4.85 (0–24)	4.50 ± 3.61 (0–19)	0.076
	Cognitive concerns	3.48 ± 4.42 (0–21)	2.57 ± 3.35 (0–18)	0.014*
	Social concerns	9.24 ± 5.09 (0–21)	6.06 ± 4.26 (0–22)	<0.001**
eSAQ		58.38 ± 14.48 (35–120)	61.71 ± 14.10(29–110)	0.021*

Note. ASI‐3: Anxiety Sensitivity Index‐3; BPQ: Body Perception Questionnaire; DDF: difficulties in describing feelings; DIF: difficulties identifying feelings; EOT: externally oriented thoughts; eSAQ: electronic version of Self‐Awareness Questionnaire; TAS‐20: Toronto Alexithymia Scale.

^* ≤0.05.

^** ≤0.001.

3.2. Data quality and acceptability

For the English sample, the SAQ had 12.4% missing data. Skewness was 0.972 and kurtosis was 1.7. The assumption of normality was violated (Shapiro–Wilks = p < 0.001). Floor and ceiling effects were within acceptable ranges of <10%.

For the Italian sample, the SAQ had 18.9% of missing data. Skewness was 0.739 and kurtosis was 0.834. The assumption of normality was violated (Shapiro–Wilks = p < 0.01). Floor and ceiling effects were within the acceptable range of <10%.

3.3. Factor analysis

For the English sample, seven factors with eigenvalues of greater than 1 were identified, these explained 46.05% of the variance. The screeplot suggested a two‐factor structure accounting for 29.84% of the variance. The first factor included 14 items related to interoceptive urges and visceral pain (Items 4, 7, 9, 10, 11, 14, 15, 17, 18, 21, 25, 32, 33, and 34). The second factor included 12 items related to interoceptive experiences and bodily pain (Items 3, 6, 12, 13, 19, 23, 24, 26, 27, 28, 30, and 35). Two items did not load onto either factor above the criterion of 0.30 (Items 16 and 31). Factor loadings are shown in Table 3.

Table 3.

Factor loadings of UK sample two‐factor structure

		Factor
Item number	Summary description of question	1	2
18	Pain in stomach	0.705
17	Burning stomach	0.699
4	Feel hot	0.563
9	Hunger pangs	0.529
21	Throw up	0.459
10	Backache	0.452
7	Stomach tightening	0.431
11	Pins and needles	0.410
34	Sweaty palms	0.410
15	Urge to urinate	0.406
33	Feel faint	0.370
25	Throat dry	0.321
14	Full and bloated	0.320
32	Lump in throat	0.301
16	On fire
27	Heart thudding		−0.723
23	Chilled		−0.714
19	Feel cold		−0.621
26	Heavy chest		−0.537
13	Strong heart beat		−0.530
12	Not enough air		−0.514
3	Feel heart beat		−0.502
24	Legs heavy		−0.477
28	Sudden thirst		−0.457
35	Difficulty swallowing		−0.408
30	Breathless without exertion	0.331	−0.335
6	Excessive pain		−0.314
31	Ears burning
Cronbach's alpha [95% confidence interval]		0.83 [0.80, 0.86]	0.85 [0.82, 0.88]

For the Italian sample, eight factors with eigenvalues greater than 1 were identified, these explained 49.70% of the variance. The screeplot suggested a two‐factor structure accounting for 30.93% of the variance. The first factor included 19 items related to interoceptive experiences and urges and bodily pains (Items 3, 6, 7, 10, 11, 12, 13, 14, 17, 18, 19, 21, 23, 24, 26, 27, 28, 32, and 33). The second factor included seven items related to stress (Items 4, 16, 25, 30, 31, 34, and 35). Two items did not load onto either factor above the criterion of 0.30 (Items 9 and 15). Factor loadings are shown in Table 4.

Table 4.

Factor loadings of Italian sample two‐factor structure

		Factor
Item number	Summary description of question	1	2
7	Stomach tightening	0.814
21	Throw up	0.684
17	Burning stomach	0.672
23	Chilled	0.605
14	Full and bloated	0.596
18	Pain in stomach	0.568
19	Feel cold	0.547
26	Heavy chest	0.528
33	Feel faint	0.516
13	Strong heart beat	0.506	0.308
32	Lump in throat	0.470
6	Excessive pain	0.465
28	Sudden thirst	0.455
24	Legs heavy	0.451
27	Heart thudding	0.441	0.308
12	Not enough air	0.413
3	Feel heart beat	0.376
11	Pins and needles	0.370
10	Backache	0.356
31	Ears burning		0.634
16	On fire		0.577
4	Feel hot		0.526
30	Breathless without exertion		0.434
34	Sweaty palms		0.425
25	Throat dry		0.383
35	Difficulty swallowing		0.335
9	Hunger pangs
15	Urge to urinate
Cronbach's alpha [95% confidence interval]		0.89 [0.86, 0.91]	0.70 [0.62, 0.77]

3.4. Internal consistency

For the English sample, the SAQ showed excellent internal consistency, Cronbach's α = 0.90; 95% confidence interval (CI) [0.88, 0.91]. Internal consistency was good for the two factors of the SAQ: Factor 1, Cronbach's α = 0.83; 95% CI [0.80, 0.86], and Factor 2, Cronbach's α = 0.85; 95% CI [0.82, 0.088].

The Italian sample SAQ showed good internal consistency, Cronbach's α = 0.89; 95% CI [0.87, 0.91]. Factor 1 showed good internal consistency, Cronbach's α = 0.89; 95% CI [0.86, 0.91], whereas Factor 2 was acceptable, Cronbach's α = 0.70; 95% CI [0.62, 0.77].

3.5. Construct validity

In the English sample, the SAQ total score was significantly correlated with both F1 (r = 0.906, p < 0.001) and F2 factors (r = 0.875, p < 0.001); the two factors were significantly correlated to each other (r = 0.618, p < 0.001). Correlation analyses showed that the SAQ was correlated with the TAS‐20, the BPQ, and the ASI‐3, as well as with their subscales. Only the TAS‐20 factor “externally oriented thinking” did not show any significant correlation with the SAQ or with its two factors. All the correlations were positive, meaning that high scores on the SAQ and on its factors were associated with higher scores on the questionnaires assessing alexithymia (difficulty identifying and describing feelings), bodily sensations perception, and anxiety sensitivity. Correlation scores between SAQ and other instruments for the English sample are shown in Table 5.

Table 5.

Correlation between SAQ and other questionnaires for English sample

	TAS‐20 total	TAS‐DIF	TAS‐DDF	TAS‐EOT	BPQ_Aw	BPQ_Au	ASI‐3 total	ASI‐3 PC	ASI‐3 CC	ASI‐3 SC
SAQ	0.423**	0.531**	0.364**	0.003	0.569**	0.761**	0.585**	0.543**	0.529**	0.441**
SAQ‐Factor 1	0.286**	0.423**	0.227**	−0.067	0.480**	0.668**	0.561**	0.536**	0.528**	0.389**
SAQ‐Factor 2	0.444**	0.495**	0.405**	0.067	0.532**	0.680**	0.475**	0.416**	0.412**	0.397**

Note. ASI‐3: Anxiety Sensitivity Index‐3; BPQ: Body Perception Questionnaire; DDF: difficulties in describing feelings; DIF: difficulties identifying feelings; EOT: externally oriented thoughts; SAQ: Self‐Awareness Questionnaire; TAS‐20: Toronto Alexithymia Scale.

**

The Italian sample SAQ total score was significantly correlated with both F1 (r = 0.950, p < 0.001) and F2 factors (r = 0.736, p < 0.001); the two factors were significantly correlated to each other (r = 0.632, p < 0.001). All scores were significantly correlated with the SAQ score, except TAS‐20 factor “externally oriented thinking” and the BPQ_AU subscale. Factor 1 of the SAQ was not significantly correlated with the TAS‐20 Factor 2 assessing “difficulty describing feelings”, neither was Factor 2 of the SAQ with “social concerns” subscale of the ASI‐3. Finally, all the significant correlations were positive, meaning that high scores on the SAQ and its factors were associated with higher scores on the questionnaires assessing alexithymia (difficulty identifying or describing feelings), bodily sensations awareness, and anxiety sensitivity. Correlation scores between SAQ and other instruments for the Italian sample are shown in Table 6.

Table 6.

Correlation between SAQ and other questionnaires for Italian sample

	TAS‐20 total	TAS‐DIF	TAS‐DDF	TAS‐EOT	BPQ_aw	BPQ_au	ASI‐3 total	ASI‐3 PC	ASI‐3 CC	ASI‐3 SC
SAQ	0.360**	0.491**	0.259**	−0.020	0.583**	0.119	0.547**	0.351**	0.479**	0.415**
SAQ‐Factor 1	0.192*	0.309**	0.122	−0.058	0.459**	0.042	0.411**	0.315**	0.297**	0.312**
SAQ‐Factor 2	0.249**	0.314**	0.221**	−0.019	0.469**	0.072	0.300**	0.206**	0.330**	0.165

Note. ASI‐3: Anxiety Sensitivity Index‐3; BPQ: Body Perception Questionnaire; DDF: difficulties in describing feelings; DIF: difficulties identifying feelings; EOT: externally oriented thoughts; SAQ: Self‐Awareness Questionnaire; TAS‐20: Toronto Alexithymia Scale.

* **

4. DISCUSSION

The goal of the present study was to validate an electronic version of the SAQ in English and Italian samples. Both versions of the SAQ demonstrated good internal consistency and produced a two‐factor structure. For the English version of the SAQ, the first factor was mainly related to interoceptive urges and visceral pain; the second factor was related to bodily pain. For the Italian version of the SAQ, the first factor was mainly related to interoceptive urges and bodily pain whereas the second factor was related to stress.

Emerging literature suggests that alexithymia is the outcome of an interoceptive failure (Betka et al., 2017; Brewer et al., 2016; Murphy et al., 2017; Shah et al., 2016). The findings presented above show that the SAQ and its subscales were positively correlated with difficulties in identifying feelings. In the Italian sample, difficulties in describing feelings were not correlated with the interoceptive urges and bodily pain factor. This finding is consistent with recent studies showing that interoceptive accuracy better predicts difficulties in identifying feelings than other alexithymic features (Betka et al., 2017; Bornemann & Singer, 2017). Furthermore, externally oriented thinking did not correlate with the SAQ or its subscales in any of our samples. This was also observed in the validation of the paper and pencil version of the SAQ (Longarzo et al., 2015) and may be explained by the lack of internal reliability of the TAS‐20 third factor (Taylor, Bagby, & Parker, 2003).

Even if the factors of both the English and Italian samples were tapping into similar dimensions (i.e., interoceptive experience and pain), differences were observed between the samples. Although the SAQ and its subscales were associated with increased autonomic nervous system reactivity in the English sample, a similar relationship was not found in the Italian sample. These discrepancies may be explained by differences between the two samples. English participants reported more alexithymic traits and had higher scores on the anxiety sensitivity index for cognitive and socials concerns compared with Italian participants. However, Italian participants reported greater autonomic reactivity compared with English participants.

Extended work in psychology has explored how different cultures shape emotional regulation and self‐expression (Ford & Mauss, 2015; Kim & Sherman, 2007). For example, it has been shown that cultural context modulates expressive suppression of emotion and can have impacts on psychological functioning (Butler, Lee, & Gross, 2007; Soto, Perez, Kim, Lee, & Minnick, 2011). It is also possible that English and Italian participants report subjective responses differently. It has been shown that survey response style is strongly influenced by cultural models (Smith et al., 2016). Culture not only impacts self‐assessment reports but also objectively impacts physiological responses to emotions (Lim, 2016). For example, reduced cerebral activity during suppression of emotional expression is observed in Asian participants compared with European Americans (Murata, Moser, & Kitayama, 2013).

Interoception is an important component of emotional regulation, and it is recognized that bodily state representations are also shaped by cultures (Ma‐Kellams, 2014). It has been shown that European Americans have better abilities in perceiving bodily sensations (i.e., interceptive accuracy) compared with West Africans or Asians (Chentsova‐Dutton & Dzokoto, 2014; Ma‐Kellams, Blascovich, & Mccall, 2012). The prevalence of alexithymia is also different across countries. In Finland, the prevalence of alexithymia is 13%, whereas in France 23% of a nonclinical sample was labelled as alexithymic (Loas, Fremaux, Otmani, & Verrier, 1995; Salminen, Saarijarvi, Aarela, Toikka, & Kauhanen, 1999). In Great Britain, 18% of students were found to be alexithymic whereas the prevalence in Italy was approximately 10% (Mason, Tyson, Jones, & Potts, 2005; Scimeca et al., 2013).

Discrepancies in semantics and concepts related to emotional and bodily awareness between English and Italian populations might also explain our findings. Even if a shared model for the semantic structure of emotion terms seems to exist, some robust differences have been observed between English and Japanese native speakers (Romney, Moore, & Rusch, 1997). Finally, the factor analysis results reported above differ from the factor structure of the paper and pencil SAQ version (Longarzo et al., 2015). Items of the paper–pencil SAQ version clustered onto two factors, with the first mainly relating to visceral feelings and the second to somatosensory feelings. These discrepancies might be explained by the different methods of administration and completion that were used. Electronic versions of questionnaires are often preferred as they have better participation rates and can reduce the incidence of missing data. However, studies have found differences between electronic and paper–pencil versions of the same questionnaire (Galliher et al., 2008; Van De Looij‐Jansen & De Wilde, 2008; Van Gelder et al., 2013). Further studies are needed to explore the impact of questionnaire administration on subjective ratings.

Finally, the results of the study should be considered in light of several limitations. The size of the English sample was larger than the Italian sample. This might explain the difference in factor structures between the two samples and between the findings reported in this paper and the original study by Longarzo et al. (2015). In addition, the two samples differed in occupation: The English sample was mainly composed of students; whereas the Italian sample was composed of more professionals. Further studies should consider difference in education while assessing the relationship between alexithymia and subjective interoceptive ability.

This study adds to the existing literature on the relationship between interoception and alexithymia by showing that the relationship is observed across different populations. From a clinical point of view, we validated a new electronic version of SAQ in English and Italian languages. This novel tool might help the pragmatic evaluation of bodily signal sensitivity and inform the development of a new therapy targeting interoceptive processes, in a wide range of psychopathological conditions. Furthermore, the electronic version of SAQ could be useful as a variable of interest for correlation studies between bodily awareness and neuroimaging studies in clinical populations.

DECLARATION OF INTEREST STATEMENT

The authors declare they have no conflict of interest.

AUTHOR CONTRIBUTION

All authors were responsible for the concept and design of the study and contributed to data acquisition. All authors assisted with data analysis and interpretation of findings and drafted and provided critical revision of the manuscript for important intellectual content. All authors critically reviewed content and approved the final version for publication.

Hughes L, Betka S, Longarzo M. Validation of an electronic version of the Self‐Awareness Questionnaire in English and Italian healthy samples. Int J Methods Psychiatr Res. 2019;28:e1758. 10.1002/mpr.1758