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Psychometric properties of the emotional processing scale in individuals with psychiatric symptoms and the development of a brief 15-item version

The 25-item Emotional Processing Scale (EPS) can be used with clinical populations, but there is little research on its psychometric properties (factor structure, test–retest reliability, and validity) in individuals with psychiatric symptoms. We administered the EPS-25 to a large sample of people (N = 512) with elevated psychiatric symptoms. We used confirmatory factor analysis to evaluate three a priori models from previous research and then evaluated discriminant and convergent validity against measures of alexithymia (Toronto Alexithymia Scale-20), depressive symptoms (Patient Health Questionaire-9), and anxiety symptoms (Generalized Anxiety Disorder-7). None of the a priori models achieved acceptable fit, and subsequent exploratory factor analysis did not yield a clear factor solution for the 25 items. A 5-factor model did, however, achieve acceptable fit when we retained only 15 items, and this solution was replicated in a validation sample. Convergent and discriminant validity for this revised version, the EPS-15, was r = − 0.19 to 0.46 vs. TAS-20, r = 0.07− 0.25 vs. PHQ-9, and r = 0.29− 0.57 vs. GAD-7. Test–retest reliability was acceptable (ICC = 0.73). This study strengthens the case for the reliability and validity of the 5-factor structure of the EPS but suggest that only 15 items should be retained. Future studies should further examine the reliability and validity of the EPS-15.

Emotional processing deficits in individuals with elevated psychiatric symptoms. According to the EPM, a lack of adequate emotional processing will be associated with psychiatric and medically unexplained somatic symptoms 1,2,5 . Consistent with this hypothesis, emotional processing deficits have been identified in patients with psychogenic nonepileptic seizures 6 , functional neurological symptoms 7 , irritable bowel syndrome (IBS) 8 , chronic (back) pain 9,10 , post-traumatic stress disorder (PTSD) 11,12 , substance use disorder 12 , bipolar disorder 10 , and anxiety disorders 13 . Emotional processing deficits do not appear to be specific to psychiatric populations, however, as deficits have also been identified in populations of people with medical conditions such as ischemic heart disease 14 , multiple sclerosis 10,15 and type 2 diabetes 16 .
Moreover, although several psychometric studies of the EPS-25 have been published, most of these studies have examined the EPS-25 in non-psychiatric samples, such as healthy participants, medical patients, or a combination of these [17][18][19][20] . Of the few validation studies on people with psychiatric problems, one had a small highly selected sample (24 patients with bipolar disorder hospitalized for depression) 10 , and the other investigated an unspecified population (people referred to a psychologist for various mental health problems) 2 . Thus, further validation of the factor structure of the EPS-25 in a large sample of people with psychiatric symptoms is needed as an initial step in determining the validity of this measure as a predictor of the development and maintenance of both psychiatric disorders and functional somatic syndromes.
Internal consistency and dimensionality. There have been several psychometric studies on the EPS-25, and studies generally report excellent internal consistency for the whole scale, and fair to good internal consistencies for the subscales 2,10,17,[19][20][21][22][23] . In Baker et al. 's (2010) original article, the EPS-25 was administered to a mixed sample of 690 medical patients, psychiatric patients, and healthy controls 2 . Exploratory factor analysis revealed the 5-factor structure described above. Moreover, Gay et al. (2019) administered the EPS-25 to a combined sample of 1176 medical patients, hospitalised patients with bipolar disorder, city hall employees, and students 10 . An exploratory factor analysis with five factors defined a priori revealed factor loadings similar to those reported by Baker et al. (2010), although five items had cross-loadings over 0. 30. Other attempts to replicate the original 5-factor solution, however, have failed. Using two community samples (N = 1172), Spaapen (2015) conducted a confirmatory factor analysis of the 5-factor solution suggested by Baker et al. (2010), but this factor structure did not achieve acceptable fit, either in its original form or after dropping the three most problematic items 18 . Orbegozo et al. (2018) investigated the factor structure of the EPS-25 with confirmatory factor analysis in school and university students (N = 605), but the original 5-factor model did achieve an acceptable fit 20 . Moreover, neither Kharamin et al. (2021), who used a confirmatory factor analysis of the EPS-25 among university students (N = 1283) 19 , nor Lauriola et al. 17 , who administered the EPS-25 to a combined sample of gastrointestinal patients and healthy participants (N = 696), replicated the original 5-factor structure.
Given that replication of the original findings of Baker et al. (2010) has proven difficult, several authors have explored alternative structures. Spaapen (2015) investigated a 2-factor model, with Suppression as one factor, and the other four subscales representing another factor, but confirmatory factor analysis did not establish a convincing model fit 18 . Other authors have added a second-order latent "emotional processing" factor (i.e., a general emotional processing capacity factor) to the five subfactors, which increased model fit 17,19 . Another solution has been to reduce the number of items or move items among factor to achieve adequate fit 20 .
Taken together, despite difficulties in replicating Baker et al. 's (2010) original findings, most previous studies support a 5-factor model, either with a second-order latent "emotional processing" factor 17,19,20 or without one 2,10 , although establishing a 5-factor model required revisions in some studies, such as reducing items 18,20 . Thus, the structure of the EPS-25 proposed by Baker et al. (2010) is far from consistently replicated and needs further study.
Convergent and discriminant validity. The validity of a measure can be assessed by the correlations it has with other measures of relevance. Because the EPS-25 purports to assess dysfunctional emotional processing, it should correlate relatively highly (convergent validity) with measures of similar constructs, such as alexithymia (i.e., difficulties identifying and expression emotions), but correlate less strongly (discriminant validity) with measures of constructs not directly part of emotional processing (such as depression).
The convergent validity of the EPS has been studied in relation to concepts such as emotional control 1 , emotional regulation 10,20 , and alexithymia 1,2 . In particular, the Impoverished emotional experience factor of the EPS-25 has been proposed 1,2 as similar to the alexithymia facet of difficulties identifying one's own feelings (measured by the Toronto Alexithymia Scale-20); however, surprisingly low concurrent validity (r = 0.35) has been found 10,24 . In addition, the discriminant validity of the EPS-25 has been mixed, particularly findings of a larger than hypothesized relationship between the scale and measures negative affect such as anxiety (r = 0.47 to 0.59) and depressive symptoms (r = 0.48 to 0.63) 10,19,20 . Emotional processing is also proposed to have discriminant validity with another facet of the alexithymia 1 , external oriented thinking (Toronto Alexithymia Scale-20, facet 3), and studies have found that the EPS-25-total is uncorrelated with this subscale 10  Study aims and hypotheses. The planned aim of this study was to conduct a structural validation of the EPS-25 in a sample of patients with elevated psychiatric symptoms. We hypothesized that the EPS-25 would show either a 5-factorial structure (with or without a higher-order, general emotional processing capacity latent factor) consistent with the description of Baker et al. (2010), or a 2-factorial structure consistent with Spaapen's (2015) description of the two factors. We also hypothesized that the internal consistency would be good (α ≥ 0.80) for the EPS-25 total scale and at least fair for the five subscales (α ≥ 0.60). We also tested convergent validity of the EPS-25 with the Toronto-Alexithymia Scale-20 (TAS-20), hypothesizing a relatively high correlation (r = 0.50 to 0.75) with the TAS-20 factor 1 (Difficulty Identifying Feelings). For discriminant validity, we hypothesized that the association of EPS-25 with anxiety and depression would be lower (r = 0.25 to 0.50) than the EPS relationship with TAS-20. We also expected that the EPS would not be correlated with external oriented thinking from the TAS-20. A last aim of this study was to evaluate EPS test-retest reliability, which was hypothesized to have an adequate test-retest reliability (i.e., ICC ≥ 0.60) over approximately 1 week. Finally, as we conducted analyses of the EPS-25, we developed an additional aim, which was to investigate whether a shorter version of the scale might be psychometrically sound.

Method
Sources of the data and participants. Data for this study were taken from the baseline (pre-intervention) assessment of four clinical trials of internet-delivered psychodynamic treatment [25][26][27][28] . These trials were conducted on people with an anxiety disorder or depression 25 , social anxiety disorder 26 , or somatic symptom disorder 27 . In all studies, adult participants were recruited from the community by advertisement and were enrolled using a safe internet platform. The main common exclusion criterion were the presence of other major psychiatric conditions, where outpatient care would be more appropriate (e.g., psychosis, suicidal ideation).
In add trials, participants completed self-report questionnaires, from home, on a secure web platform. Traffic with the web platform was encrypted, and all studies proceeded in accordance with relevant data management and privacy legislation. For further information about recruitment procedures and patient criteria, see the original studies. The research was performed in accordance with the Declaration of Helsinki, all participants (N = 512) provided informed consent, and all four trials were conducted in accordance with relevant regulations and approved by the appropriate regulatory authorities ( For factor analyses of the EPS-25, data from all four trials were used. For analyses of discriminant and convergent validity, data were taken from the baseline of only one trial 28 that had data on the other validations measures. To calculate test-retest reliability, data came from only one trial 27 that had an adequate number of days (Range: 5-12 days) between the first and second administrations of the EPS-25 prior to treatment.

Measures. The Emotional
Processing Scale (EPS-25) has 25 items which are rated on a 10-point scale from 0 (completely disagree) to 9 (completely agree). The mean of all items yields the overall score, and means of the five, 5-item subscales are also calculated: avoidance, suppression, impoverished emotional experience, signs of unprocessed emotions, and unregulated emotions. The EPS-25 was translated from English to Swedish by three people fluent in both languages, by using multiple back-and-forth rounds until a satisfactory translation was reached 29 . (For further details, see 30 ).
The Toronto Alexithymia Scale (TAS-20) has 20 items rated on a scale of 1 (strongly disagree) to 5 (strongly agree) 31,32 , and fields a total score (range: 20 to 100) as well as scores on three facets or subscales: difficulty identifying feelings (DIF), difficulty describing feelings (DDF), and externally-oriented thinking (EOT). The TAS-20 has shown both good internal consistency and test-retest reliability in the Swedish population 33 .
The (2) a 5-factor model with a second order "emotional processing" latent variable as found to be adequate in previous studies 17,19 ; and (3) a 2-factor model with suppression and other factors as discussed by Spaapen (2015) 18 . Criteria for good model fit were: CFI and TLI at least 0.90 (ideally 0.95), RMSEA and SRMR < 0.08, and lowest possible AIC and BIC 36 .
Using Jamovi 37 , we analysed EPS internal consistency (Cronbach's α), investigated convergent and discriminant validity using Pearson correlations, and estimated test-retest reliability using the intraclass correlation coefficient (ICC). For the α statistic, values ≥ 0.90 are commonly regarded excellent, ≥ 0.80 good, and ≥ 0.70 acceptable. Importantly however, α also decreases substantially with fewer items in a scale; for example, going from 5 to 3 items could be expected to lower α around 0. 10

Results
Psychometric analysis of the EPS-25. Confirmatory factor analysis (CFA) of EPS-25. Because kurtosis was high for several items, and some items had many zero scores, models were fit using maximum likelihood estimation with robust (Huber-White) standard errors and a scaled test statistic. In the CFA using all data, none of the three a priori models of EPS-25 achieved adequate fit (see Table 1). Theoretically sound changes in accordance with modification indices, including the removal items (6,8,14,17,23) and the specification of reasonable residual covariance (for example 18,19), also did not yield acceptable model fit. Due to software limitations, fewer fit indices are provided for the EFA models. 2F two-factor, 5F five-factor, AIC Akaike information criterion, BIC Bayesian information criterion, CFI comparative fit index, EPS-15 15-item version of the emotional processing scale, MOI 20 largest modification indices (1-df), RMSEA root mean square error of approximation, SRMR standardized root mean square residual, TLI Tucker Lewis index. a Loadings on the latent "emotional processing" factor. b Arguably the most promising model according to the scree plot, with a clear increase in eigenvalue and deviation from factors derived from simulated data occurring between factor 3 and 2 (see Fig. 1). c Note that while all 25 items were included in the analysis, none of the factor solutions derived from EFA resulted in all 25 items having factor loadings of at least 0.4 on at least one factor. For example, in the 5-factor solution derived from EFA, items 9, 10, and 14 did not load 0.4 or higher on any factor, which means that this was in effect a 22-item solution. d This is the final 15-item factor solution, reached primarily via stepwise modification of the original CFA a priori 5F (non-two-tier) model. See the main text for details. Convergent and discriminant validity of EPS-25. As seen in Table 2, the EPS-25-total showed strong correlations with anxiety (r = 0.66) and depression (r = 0.59). A moderate correlation of impoverished emotional experience and the alexithymia factor difficulty identifying feelings (TAS-20, factor 1) was found (r = 0.35) but also a weak correlation (r = 0.21) with externally-oriented thinking (TAS-20, factor 3).

Development and validation of the EPS-15.
Because we could not replicate any of the a priori factor structures for the 25-item version of EPS using confirmatory factor analysis, we attempted to find a more suitable factor solution using exploratory factor analysis. Also, although the EPS-25 showed good internal consistency and test-retest reliability, discriminatory validity was unsatisfactory. The EPS-25 had large relationships with depression and anxiety and also was correlated with externally-oriented thinking of the alexithymia constructfindings that are not predicted by Baker et al. 1 .
To find and validate a better factor solution, the sample was split into training (n = 262) and validation (n = 250) subsamples by randomization. We deemed these sample sizes adequate for factor analysis considering that they were close to the common recommendation of 300 40 , and we expected communalities to be at least moderate 41 . We then conducted an exploratory factor analysis (EFA) based on principal axis factoring with promax (oblique) rotation, with the intention of finding an empirically-and theoretically-sound factor solution for the data. In these analyses, we explored 1-, 2-, and 5-factor solutions as informed by the scree plot (see Fig. 1) and our theoretical understanding of the scale and the emotional processing model. We wanted to achieve distinct factors as characterized by factor loadings of all items ≥ 0.30 (ideally ≥ 0.40), with few or no substantial cross-loadings, and at least three items loading on each factor.

Exploratory factor analysis (EFA) of the EPS-15.
The training data set was suitable for factor analysis (Barlett's test p < 0.001; KMO = 0.91). The screen plot (Fig. 1) was inconclusive; the knee being indicative of 1-or more probably 2-factors, while parallel analysis resulted in weaker eigenvalues up to factor 5, even though the difference was small for factors 3 to 5. However, none of the freely estimated 1-, 2-, or 5-factor solutions for the EPS-25 could achieve acceptable fit with distinct factors, meaning that each of all 25 items had factor loadings of at least 0.40 with minimal cross-factor loadings (see Table 1).

Development and dimensionality of the EPS-15.
As neither confirmatory nor exploratory factor analysis resulted in an acceptable factor solution for the EPS-25, we sought to develop a shorter scale scale, the EPS-15, with a more distinct factor structure. We intended to identify a subset of the EPS-25 items that would allow for stronger model fit and distinct, yet correlated, factors. To achieve this goal, we based the item selection process on the best fitting 25-item CFA model (this had 5 factors corresponding to the conventional subscale scoring), and the stepwise deletion of items, and addition of covariance if theoretically feasible, based on modification indices and our theoretical understanding (see Table 1), until exactly 3 items remained for each of the 5 factors. We subsequently validated this model in the validation data set.
Further statistical and theoretical considerations. Based on modification indices for the 25-item CFA training data 5-factor solution, item 6 ("Could not express feelings") was moved to the impoverished emotion factor. The following 10 items were then removed step by step: 23,17,8,14,5,6,20,19,11, and 12. We found the correlation between the unregulated emotions and suppression factors to be unsatisfactory (r = 0.31, i.e., clearly lower than 0.40) and therefore replaced item 18 ("Felt urge to smash something") with item 8 ("Reacted too much to what Table 2. Correlations between the Emotion Processing Scale (EPS-25) and measures of alexithymia (TAS-20), anxiety (GAD-7), and depression (PHQ-9) (N = 74) 28 . *P < 0.05, **P < 0.01, ***P < 0.001. To reach the best suiting 15 items of the 25 items available, the items were also scrutinized for adequate content validity by D.M and R.J, who, at that time, did not know of what 15 item the structural validation had suggested (see Table 3). The items were deemed either fully indicative of its subfactor (coded as "yes"), only partly so (coded as "borderline") or not an adequate description of content validity (coded as "no"). Following these considerations, one additional change of the EPS-15 was made as we did not regard item 10 ("My feelings did not seem to belong to me") as a convincing example of impoverished emotional experience understood as alexithymia 42 and therefore instead reintroduced item 5 ("My emotions felt blunt/dull"; see Table 3).

EPS-25 total Avoidance Suppression
The resulting 15-item 5-factor model (from both statistical and theoretical considerations) had improved model fit in the training data and acceptable, though not ideal, fit in the validation data (see Table 1). The average variance extracted was 47% in both the training and validation data. All factor correlations and factor loadings were 0.40 or higher in the training data and remained so in the validation data, except for the correlation between the unregulated emotions and suppression factors, which dropped to 0.36 in the validation.
Internal consistency of the EPS-15. As shown in Table 4, Cronbach's alpha was good for the EPS-15 overall scale (α = 0.87) and for the suppression subscale (α = 0.83), and acceptable (α = 0.62-0.76) for the remaining subscales. The composite reliability coefficient (ω) was almost identical. Table 5, the EPS-15 had a strong correlation with anxiety (r = 0.57). but a weak correlation with depressive symptoms (r = 0.25). Moreover, we found a moderate correlation between impoverished emotional experience and the alexithymia factor difficulty identifying feelings (r = 0.46), but no significant correlation with external oriented thinking style (TAS-20, factor 3).

Discussion
Based on data from 512 individuals with elevated psychiatric symptoms, we could not find a satisfactory factor solution for the 25-item Emotional Processing Scale. This led us to develop a briefer 15-item version of the scale, the EPS-15, for which we found an acceptable 5-factor solution that we validated using a split sample strategy. EPS-15 had good internal consistency and test-retest reliability and demonstrated discriminant validity from the construct of depressive symptoms, although less so from anxiety symptoms.
Inconsistent findings pertaining to the EPS-25. Evidence pertaining to the factor structure of the EPS-25 was inconsistent. On the one hand, the training data scree plot appeared to be indicative of one or probably two factors (suppression vs. other). On the other hand, in parallel analysis, higher eigenvalues were obtained up to the fifth factor, and a 5-factor solutions was most promising in terms of model fit under both CFA and EFA. Most previous studies appear to speak for some type of 5-factor model, sometimes with a second order latent "emotional processing" factor 17,19,20 , but sometimes not 2,10 . There are several potential explanations for the www.nature.com/scientificreports/ difficulties we encountered in replicating these 5-factor solutions. In CFA, as suggested by Lauriola et al. 17 , poor fit may have been a result of this type of model not allowing for cross-loadings over factors in the same manner as EFA, which was used in the original publication 2 . However, undue reliance on cross-factor loadings for model fit could also indicate poorly defined factors. The existence of weak main factor loadings, in combination with strong cross-loadings, speaks against scoring of the five conventional subscales, and the brief EPS-15 did indeed achieve acceptable fit under CFA. Importantly, in our data, the EPS-25 5-factor EFA model, for which item factor loadings were estimated freely, was also not satisfactory, especially as it had a pattern of factor loadings that was clearly inconsistent with the conventional scoring of the EPS-25 subscales; items 6, 8, 19, 23 exhibiting crossloadings and items 9, 10, 14 not belonging to any factor. Table 3. Comparison between blinded theoretical judgment (by DM and RJ), initial empirical suggestion of problematic items, and the final EPS-15. EPS-15 Emotional processing Scale. Yes: endorsed as an item typical what the subscale is supposed to measure. No: not endorsed. Borderline: neither typical nor atypical. a This is the sum of all modification indices pertaining to item-factor cross-loadings for each item, as based on the top 30 modification indices for the a priori 5-factor solution for the EPS-25 when fitted on the training data. Note that while there is considerable overlap between blinded theoretical judgments, these modification indices, and the final EPS-15, the reduction of the number of items from 25 to 15 was an iterative process where modification indices were examined for several intermediate scale forms, which for example is why we ultimately decided to include item 5 over items 10 and 20 in the EPS-15. Considering that all item factor loadings were 0.40 or higher, and acceptable model fit was achieved in the CFA framework without the need to specify crossloadings (that is, each item loaded only on its intended factor), the factor solution appeared to support scoring of five separate subscales. The EPS-15 demonstrated discriminant validity from the construct of depressive symptoms, although to a lesser degree of anxiety symptoms. In previous studies, the EPS-25 has not shown adequate discriminant validity from either depressive or anxiety symptoms 10,19,20 , and we also found that the EPS-25 had an substantial relationship with both anxiety symptoms and depressive symptoms. Moreover, it has been suggested 1 that the EPS should not correlate with the Toronto Alexithymia Scale-20, externally-oriented thinking subscale, but in previous studies, subscales of the EPS-25 have been found to correlate significantly, albeit weakly, with this alexithymia facet 24 . Moreover, two of the EPS-25 subscales in this study had moderate correlation with externally-oriented thinking, but this was not the case for the EPS-15, further strengthening EPS-15 discriminant validity.
In the only two previous studies that have researched EPS-25 test-retest reliability, this has found to be good to excellent 2,19 . In the current study, both EPS-25 and EPS-15 demonstrated good test-retest reliability over approximately 1 week.
Compared to the EPS-25, the shorter EPS-15 will be easier to administer and complete, especially when used in combination with other scales (such as in routine care screening batteries), when space is limited (such as in epidemiological research), and when repeated measurements are conducted (such as during treatment). Moreover, without losing any of the important psychometric strengths of the EPS-25 (i.e., internal consistency, test-retest reliability), the EPS-15 was better able to discriminate emotional processing from depressive symptoms and facets of the alexithymia construct.
Limitations. There are several limitations of this study. The test-retest reliability and the convergent and discriminant validation analyses was conducted on a small sample. Also, the use of randomization to form the testing and validation subsamples did not result in as stringent of a validation as a true replication in data from an entirely new sample. Participants in the current analyses self-selected to take engage in internet-delivered emotion-focused treatments, and it is not clear how similar this population is to those in clinical practice or in the community, thus limiting generalizability of the findings. Moreover, the sample used for studying concurrent and discriminant validity were all diagnosed with somatic symptom disorder, and generalization to other samples, including healthy people and those with other psychiatric conditions, is limited.
The difficulties replicating the Baker et al. (2010) original 5-factor structure with adequate factor loadings for 25 items in this study could partly stem from our population studying individuals with elevated psychiatric symptoms. Almost all previous validation studies were on healthy samples and/or medical populations [17][18][19][20] . Emotional processing difficulties might differ between healthy people and those with elevated psychiatric symptoms.  Table 5. Correlations between the 15-item Emotional Processing Scale (and subscales) with Alexithymia (TAS-20), anxiety (GAD-7), and depression (PHQ-9 (N = 74) 28 . *P < 0.05, **P < 0.01, ***P < 0.001.  [17][18][19][20] . Moreover, to find an adequate factor solution, previous authors have excluded problematic items-in effect, shortening the original 25-item scale 18,20 . We believe that our difficulty replicating Baker et al. (2010) stems not only from differences in population but differences in factor analytic procedures and "problematic" items with cross loadings initially used to develop the psychometric properties of the EPS-25.

EPS-15 total Avoidance Suppression
Overall discussion and future studies. Despite the interest in modelling and measuring emotional processing, considerable challenges remain, and many questions require further investigation. Further structural validation studies of the EPS-15 comparing different populations (i.e., comparing psychiatric to healthy populations) would be of interest. EPS-15 convergent validity should further be clarified, relating it to other measures of emotional processing, such as emotional awareness (measured by Level of Emotional Awareness Scale) or emotional regulation (measured by Difficulties of Emotional Regulation Scale). Further item analysis of the EPS-15 would be useful, given that the average variance extracted was around 50% (barely acceptable). It would also be preferable to further reduce the error variance of the EPS-15, for example by replacing or rephrasing items with relatively low factor loadings (e.g., EPS-25 equivalent items 4, 5, 13) or a particularly poor theoretical basis (e.g., EPS-25 equivalent items 5 and 9; see Table 2). Despite continued challenges, we believe that this study contributes to the existing body of knowledge in several ways. First, an adequate test-retest reliability in a sample with elevated psychiatric symptoms (or more specifically somatic symptom disorder) has not been previously demonstrated. This is important as the EPS-25 is recommended for longitudinal psychotherapy research 1,10,17 . Second, despite reducing the number of items to 15, a 5-factor solution was retained, which is in line with previous research. This factor structure is important for clinicians, for example, who might desire to describe or address patient's difficulties in emotional processing in five different domains. Third, we believe that this study overcomes some of the methodological shortcomings in previous research of the EPS-25, and the EPS-15 holds promise in populations with psychiatric symptoms. In conclusion, the EPS-15 is a promising short-form questionnaire for basic and clinical studies, although both further research on reliability and validity should be conducted.