Alexithymia in Nursing Students and Preventive Training Strategies: A Multicenter Cross-Sectional Study

Abstract

Background: Emotional awareness is a core component of professional competence in healthcare, influencing therapeutic communication, stress regulation, and relational effectiveness. Alexithymia, defined as difficulty identifying and describing emotions, may interfere with the development of these skills during nursing education. Objective: This study aimed to evaluate the prevalence of alexithymic traits in Italian nursing students and to examine differences according to gender and academic year. Methods: A multicenter cross-sectional design was adopted. A total of 232 undergraduate nursing students from several Italian universities completed the Toronto Alexithymia Scale (TAS-20) via an anonymous online survey. Descriptive statistics, independent samples t-tests, and one-way ANOVA were performed. Results: The mean TAS-20 total score was 60.36 (SD = 11.22), approaching the clinical cutoff. Approximately 26% of students met the criteria for alexithymia. No statistically significant differences emerged across gender or academic year. A near-significant trend was observed for the Difficulty Identifying Feelings subscale (p = 0.053). Conclusions: A substantial proportion of nursing students reported elevated alexithymic traits. These findings highlight the need to strengthen emotional competence within nursing curricula to support professional development and resilience.

1. Introduction

Emotions are a fundamental component of healthcare practice, shaping interpersonal processes and influencing clinical outcomes across care settings. Patients, family members, and healthcare professionals continuously engage in emotionally laden interactions that may either facilitate or hinder therapeutic processes. The ability to recognize, interpret, and respond appropriately to emotional cues is therefore essential for building trust, promoting shared decision-making, and enhancing treatment adherence. Empathic communication plays a central role in establishing a therapeutic alliance and improving patient well-being [1,2].

In this context, emotional awareness can be defined as the ability to perceive and accurately identify one’s own and others’ emotional states, representing a foundational component of emotional functioning [3]. This construct should be clearly distinguished from related dimensions, as conceptual ambiguity may obscure its specific role in psychological and clinical processes.

This capacity is especially relevant for nurses, who are routinely exposed to complex emotional demands in clinical practice. Sustained engagement with patients experiencing pain, uncertainty, and distress requires not only technical competence but also well-developed emotional skills. Emotional competence has been conceptualized as a multidimensional construct encompassing the ability to identify, understand, express, and regulate emotions adaptively [4]. Individuals with higher emotional competence tend to demonstrate more effective communication, adaptive problem-solving, and greater resilience in stressful environments.

From a broader perspective, emotional competence can be considered closely related to emotional intelligence, which encompasses the ability to perceive, understand, and regulate emotions in oneself and others. Within this framework, emotional awareness represents a foundational component, while emotion regulation reflects a higher-order process that depends, at least in part, on the accurate identification of emotional states.

More specifically, emotional competence includes emotion regulation, defined as the set of processes through which individuals monitor, evaluate, and modify emotional reactions [5]. Related constructs such as affective awareness and affective regulation refer, respectively, to the conscious experience of affective states and their modulation. Furthermore, mentalizing—or reflective functioning—denotes the capacity to interpret one’s own and others’ behavior in terms of underlying mental states, including emotions, intentions, and beliefs [6]. Although conceptually distinct, these constructs are closely interrelated and collectively contribute to adaptive emotional functioning.

Importantly, deficits in these processes have been consistently associated with increased vulnerability to stress and burnout in healthcare professionals. In particular, insufficient emotional awareness may limit the effective use of regulatory strategies, thereby amplifying the impact of emotional labor and contributing to psychological strain.

Healthcare systems increasingly emphasize person-centered care, positioning the individual rather than the disease at the core of clinical decision-making. Within this framework, emotional and relational competencies are essential not only for interpersonal quality but also for clinical effectiveness, as they enhance diagnostic accuracy and foster patient trust. However, healthcare professionals frequently encounter emotionally demanding situations—often conceptualized as emotional labor—which may contribute to stress, fatigue, and burnout when regulatory capacities are insufficient [7,8].

Within this theoretical framework, alexithymia can be conceptualized as a specific deficit within the broader domain of emotional functioning. Rather than representing a separate construct, it reflects impairments in core components of emotional competence, particularly emotional awareness and emotional expression. In this sense, alexithymia may be understood as a vulnerability factor that limits both emotional intelligence and the effective regulation of emotional responses [9]. Importantly, alexithymia should be distinguished from, yet conceptually related to, emotional awareness and mentalizing. While these constructs involve the capacity to recognize and interpret emotional and mental states, alexithymia represents a deficit in these abilities.

Contemporary research has highlighted the relevance of alexithymia in healthcare populations. High prevalence rates have been reported among nurses, particularly in high-intensity settings such as intensive care units, where emotional demands are substantial [10]. Moreover, increasing attention has been directed toward healthcare students. Evidence suggests that alexithymia is associated with difficulties in emotion regulation and is linked to psychological distress, including anxiety, depression, and stress [11,12].

Taken together, these findings underscore the importance of conceptual clarity when addressing emotional constructs in healthcare research. Distinguishing between emotional awareness, affective awareness, emotion regulation, and mentalizing allows for a more precise understanding of how alexithymia fits within a broader framework of emotional functioning, thereby strengthening both theoretical interpretation and empirical investigation.

This perspective helps clarify the links among the constructs discussed: reduced emotional awareness (as observed in alexithymia) may hinder emotion regulation processes, which in turn increases the risk of stress and burnout in emotionally demanding professional contexts such as nursing. Framing alexithymia in this way allows for a more coherent interpretation of its role within healthcare training and practice.

Aims

Extensive evidence indicates that emotional intelligence, empathy, and mentalization abilities play a central role in nursing practice, influencing the quality of the therapeutic relationship, clinical decision-making, patient satisfaction, and the prevention of professional burnout [13,14]. Within this framework, emotional awareness represents a foundational dimension of professional competence in healthcare settings.

Given the potential impact of alexithymic traits on emotion recognition, interpersonal communication, and stress regulation, investigating their presence during undergraduate training may provide important insights into students’ emotional functioning and possible vulnerabilities.

The primary aim of this study was to assess the prevalence and distribution of alexithymia in a multicenter sample of Italian nursing students.

Secondary objectives were:

• To explore differences in alexithymia levels according to gender.
• To examine variations in alexithymic traits across different academic years, and to identify potential trends associated with clinical exposure during training.

By identifying the extent and characteristics of alexithymic traits in this population, the study seeks to contribute to the development of targeted educational strategies aimed at strengthening emotional competence and supporting professional resilience in future nurses.

Within this framework, emotional awareness should be understood as a specific and measurable component of emotional competence, rather than as a generic or interchangeable construct with related dimensions such as emotional intelligence or mentalizing.

2. Materials and Methods

2.1. Study Design

A multicenter, descriptive cross-sectional study was conducted to assess levels of alexithymia among undergraduate nursing students. The cross-sectional design was selected to provide a snapshot of emotional functioning within this population at a specific point in time and to explore the distribution of alexithymic traits across sociodemographic and educational variables. This approach allowed for the efficient collection of data from different institutions and facilitated comparative analyses across academic years and genders.

2.2. Setting

The study was carried out within Bachelor’s Degree Programs in Nursing at several Italian universities: the University of Salerno, the University of Campania “Luigi Vanvitelli,” Sapienza University of Rome, the University of Bologna, the University “Magna Graecia” of Catanzaro, and the University of Pisa.

Data were collected during the 2024/2025 academic year through an online survey. In Italy, nursing education is structured as a three-year undergraduate program integrating theoretical coursework with progressive clinical placements in hospital and community settings. All participating institutions follow nationally regulated curricula emphasizing person-centered care, professional ethics, and evidence-based practice. The online format enabled recruitment from geographically diverse areas, enhancing heterogeneity within the sample.

2.3. Participants

The target population consisted of students enrolled in undergraduate Nursing degree programs at the participating universities.

Inclusion criteria:

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Enrollment in a Bachelor’s Degree in Nursing;

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Age ≥ 18 years;

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Adequate comprehension of the Italian language;

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Provision of informed consent.

Exclusion criteria:

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Refusal or withdrawal of informed consent;

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Incomplete questionnaire responses;

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A non-probability convenience sampling strategy was employed.

A total of 232 students participated in the study, of whom 136 were enrolled at the University of Salerno and 96 at other institutions.

The final sample included 192 women and 40 men, aged between 18 and 45 years (M = 23.7). The distribution by academic year was: first year (n = 52), second year (n = 48), third year (n = 107), and students temporarily not on track with their studies (“out-of-course”; n = 25).

2.4. Sample Size Considerations

Given the exploratory nature of the study and the absence of precise national prevalence data regarding alexithymia in Italian nursing students, a formal a priori power analysis was not conducted. The sample size was determined based on feasibility and participant availability during the data collection period. The final sample was considered sufficient to provide stable descriptive estimates and to perform subgroup comparisons according to gender and academic year.

2.5. Measures

Data were collected using a structured online questionnaire composed of two sections.

• Sociodemographic and Educational Information.
• Participants provided information regarding age, gender, university affiliation, and year of study.
• Alexithymia was assessed using the 20-item Toronto Alexithymia Scale (TAS-20) [15,16], developed by Bagby and colleagues. The instrument employs a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree).

The TAS-20 comprises three subscales:

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Difficulty Identifying Feelings (DIF; 7 items);

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Difficulty Describing Feelings (DDF; 5 items);

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Externally Oriented Thinking (EOT; 8 items).

To better illustrate the operationalization of these dimensions, example items are provided. The DIF subscale includes items such as “I am often confused about what emotion I am feeling”, capturing difficulties in recognizing internal emotional states. The DDF subscale includes items such as “It is difficult for me to find the right words for my feelings”, reflecting impairments in verbal emotional expression. In contrast, the EOT subscale includes items such as “I prefer talking to people about their daily activities rather than their feelings”, representing a cognitive style oriented toward external events rather than inner emotional experiences.

These examples clarify the conceptual distinctions among the three subscales, highlighting how DIF concerns emotional identification, DDF emotional communication, and EOT a reduced focus on internal affective processes.

Total scores range from 20 to 100, with established cutoffs:

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≤51: non-alexithymic;

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52–60: borderline (possible alexithymia);

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≥61: alexithymic;

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Higher scores indicate greater alexithymic traits.

The TAS-20 has demonstrated robust psychometric properties in previous research and has been widely used in studies involving healthcare professionals and students. In the present study, internal consistency was evaluated using Cronbach’s alpha coefficient. The total scale showed good reliability (α = 0.81), exceeding the conventional threshold of 0.70. The Italian version of the instrument has been previously validated, supporting its applicability within Italian student populations.

2.6. Data Collection Procedure

Data were collected through an electronic survey hosted on an online platform. The survey link was disseminated via institutional mailing lists and academic contacts within the participating universities.

Before participation, students received an information sheet outlining the study objectives, procedures, the voluntary nature of participation, and data protection measures. Informed consent was obtained electronically before access to the questionnaire.

The survey required approximately 15 min to complete. Participation was anonymous, and no personally identifiable information was collected. To minimize duplicate responses, survey settings restricted multiple submissions from the same device. Data collection lasted approximately four weeks.

2.7. Statistical Analysis

Statistical analyses were conducted using IBM SPSS version 26.0.

Descriptive statistics were calculated to summarize sample characteristics and study variables. Continuous variables were reported as means, medians, and standard deviations, whereas categorical variables were presented as frequencies and percentages.

TAS-20 total scores were categorized according to established cutoffs to identify levels of alexithymia. Cross-tabulations were performed to examine the distribution of alexithymia categories by gender and academic year.

Given the exploratory nature of the study, analyses were primarily descriptive. When inferential tests were applied, the level of statistical significance was set at p < 0.05.

In addition to significance testing, effect sizes (Cohen’s d for independent samples t-tests and eta squared, η², for ANOVA) were reported to estimate the magnitude of observed differences. Where possible, results are interpreted in light of both statistical significance and effect size magnitude. Although confidence intervals were not systematically computed, future studies should incorporate them to provide more precise estimates of effect size and improve the robustness of statistical interpretation.

3. Results

3.1. Descriptive Statistics

The mean total score on the Toronto Alexithymia Scale (TAS-20) was 60.36 (SD = 11.22) (see

Table 1. Descriptive Statistics for TAS-20 Total and Subscales.

Scale	Mean	SD	Theoretical Range
TAS-20 Total	60.36	11.22	20–100 (Cutoff ≥ 61)
DDF	14.98	3.56	5–25
DIF	18.88	5.52	7–35
EOT	26.48	3.16	8–40

). About subscale scores, Difficulty Describing Feelings (DDF) was M = 14.98 (SD = 3.56), Difficulty Identifying Feelings (DIF) was M = 18.88 (SD = 5.52), and Externally Oriented Thinking (EOT) was M = 26.48 (SD = 3.16).

The mean total score approached the established clinical cutoff for alexithymia (≥61), indicating an overall elevated level of alexithymic traits within the sample. Notably, approximately 26% of participants fell within the alexithymic range.

This proportion appears broadly consistent with, or slightly higher than, rates reported in comparable studies involving healthcare students, which typically range between 15% and 25%, depending on the population and context. This suggests that the prevalence observed in the present sample is not anomalous but represents a clinically relevant proportion of students.

3.2. Gender Differences

Independent samples t-tests were conducted to examine gender differences in TAS-20 total and subscale scores (see

Table 2. Gender Differences in TAS-20 Scores.

Scale	Females (M ± SD)	Males (M ± SD)	t (df = 231)	p
DDF	15.07 ± 3.57	14.53 ± 3.52	0.885	0.377
DIF	18.86 ± 5.72	19.00 ± 4.47	−0.146	0.884
EOT	26.48 ± 3.15	26.50 ± 3.25	−0.033	0.974
TAS Total	60.74 ± 11.38	58.53 ± 10.40	1.137	0.257

). No statistically significant differences emerged between female and male students.

Specifically, no significant differences were found in Difficulty Describing Feelings (DDF), t(231) = 0.885, p = 0.377; Difficulty Identifying Feelings (DIF), t(231) = −0.146, p = 0.884; or Externally Oriented Thinking (EOT), t(231) = −0.033, p = 0.974. Similarly, no significant gender differences were observed in the TAS-20 total score, t(231) = 1.137, p = 0.257.

Effect size estimates (Cohen’s d) for these comparisons were small across all variables (d < 0.20), indicating negligible differences between groups even beyond statistical significance.

Female students showed slightly higher mean scores on DDF and total TAS-20, whereas male students reported marginally higher DIF and EOT scores; however, none of these differences reached statistical significance.

However, this finding should be interpreted with caution, given the marked imbalance in the sample composition, with a substantially higher proportion of female participants. Such asymmetry may have reduced the statistical power to detect potential gender differences, particularly in the male subgroup.

3.3. Differences Across Academic Years

A one-way ANOVA (see

Table 3. One-Way ANOVA Across Academic Years.

Scale	F	p
DDF	0.100	0.960
DIF	2.604	0.053
EOT	0.209	0.890
TAS Total	0.491	0.689

) was conducted to examine differences in TAS-20 scores across academic years. No statistically significant differences were found in total TAS-20 scores, F(3, 229) = 0.491, p = 0.689.

Similarly, analyses of the subscales did not reveal significant group differences. No significant effects were observed for Difficulty Describing Feelings (DDF), F(3, 229) = 0.100, p = 0.960, or for Externally Oriented Thinking (EOT), F(3, 229) = 0.209, p = 0.890.

The analysis of Difficulty Identifying Feelings (DIF) yielded a near-significant result, F(3, 229) = 2.604, p = 0.053. The corresponding effect size (η²) can be considered small to moderate, suggesting that a non-negligible proportion of variance in emotional identification may be associated with academic progression, despite the lack of conventional statistical significance.

Rather than being treated as a marginal finding, this result may indicate a potentially meaningful trend in the development (or persistence) of difficulties in emotional awareness across training years. This interpretation is further supported by the fact that DIF specifically captures the core component of emotional awareness, which represents a central dimension of alexithymia.

Although not reaching conventional levels of statistical significance, this pattern suggests that emotional awareness may vary across academic progression in subtle ways that are not fully captured by categorical comparisons alone. At the same time, the absence of significant differences in overall scores indicates that alexithymic traits, as a broader construct, may remain relatively stable throughout undergraduate training.

This pattern may imply that standard clinical training does not substantially enhance emotional processing abilities, particularly in relation to the identification of emotional states. From this perspective, the DIF trend may be especially informative, as it points to a specific component of emotional functioning that could be more sensitive to educational influences and therefore a relevant target for intervention.

4. Discussion

The present study investigated alexithymic traits in a multicenter sample of Italian nursing students. Overall, the mean TAS-20 score approached the clinical cutoff, and approximately one quarter of participants (26%) were classified as alexithymic. Although no statistically significant differences emerged across gender or academic year, the proportion of students scoring within or near the clinical range highlights a clinically relevant emotional profile within this cohort.

These findings are consistent with recent evidence indicating that alexithymia is relatively prevalent among healthcare students. However, rather than simply reiterating associations with related constructs, it is important to interpret these results within a more precise conceptual framework. In particular, alexithymia reflects a deficit primarily in emotional awareness, understood as the ability to identify and differentiate one’s emotional states, as well as in the capacity to verbalize them. This distinguishes it from broader constructs such as emotion regulation, which refers to the modulation of emotional responses, and from mentalizing, which involves interpreting behavior in terms of underlying mental states.

In line with this distinction, previous research has shown that alexithymia is associated with difficulties in emotion regulation [11], but the two constructs are not interchangeable. Rather, impaired emotional awareness may represent an upstream vulnerability that limits the effective deployment of regulatory strategies. This interpretation provides a more coherent explanation of why individuals with elevated alexithymic traits often exhibit reduced adaptive coping and increased psychological distress.

Furthermore, evidence from studies on emotional competence in nursing students suggests a tendency toward cognitive distancing and emotional detachment in response to demanding clinical contexts [17]. Within the present framework, such patterns may be understood not only as coping strategies but also as manifestations of reduced access to internal emotional states. This interpretation aligns with the externally oriented thinking dimension of alexithymia, which reflects a diminished focus on inner experiences.

Although emotional intelligence has been widely associated with clinical competence and professional effectiveness in nursing populations [18], it should not be conflated with alexithymia. While both constructs involve aspects of affective processing, emotional intelligence encompasses a broader set of abilities, including emotional understanding and regulation, whereas alexithymia specifically captures deficits in emotional awareness and expression. The inverse relationship frequently reported between these constructs may therefore reflect their positioning at opposite ends of a continuum of emotional functioning.

The relatively high levels of alexithymic traits observed in this study may be explained by the specific emotional demands of nursing education. Students are exposed early to emotionally challenging situations, including patient suffering, interpersonal tensions, and high-responsibility decision-making. In the absence of structured opportunities to process these experiences, students may adopt forms of emotional disengagement or reduced affective reflection. Over time, these patterns may consolidate into difficulties in identifying and articulating emotions.

At the same time, these interpretations should be considered in light of some methodological constraints. The use of a convenience sample limits the generalizability of the findings, and the marked imbalance in gender distribution may have reduced the ability to detect potential differences between male and female students. Therefore, the absence of significant gender effects should be interpreted with caution rather than as evidence of true equivalence.

Notably, the near-significant trend observed for the Difficulty Identifying Feelings (DIF) subscale across academic years may suggest subtle variations in emotional awareness during training. Although not conclusive, this finding points to the potential importance of longitudinal approaches to better understand how emotional processing evolves over the course of professional education.

However, the cross-sectional nature of the study does not allow for conclusions about developmental change, and the absence of significant differences across academic years should not be interpreted as evidence that emotional awareness remains stable over time. Rather, it is possible that individual trajectories are not adequately captured through between-group comparisons.

From a clinical and educational perspective, alexithymia has been associated with increased perceived stress and reduced emotion regulation capacity, factors that may contribute to vulnerability to burnout and decreased professional well-being [11]. Nevertheless, the present study did not include measures of stress, anxiety, or burnout, which limits the possibility of situating these findings within a broader psychological framework. As a result, interpretations regarding the impact of alexithymia on students’ well-being should be considered preliminary.

Although the present study did not directly assess these outcomes, the observed levels of alexithymia highlight the importance of early identification of emotional processing difficulties in healthcare students.

Educational Implications

Taken together, the present findings support the need for a more structured and theoretically grounded approach to emotional training within nursing curricula. In particular, the relatively high proportion of students scoring within or near the alexithymic range, together with the trend observed in the Difficulty Identifying Feelings (DIF) subscale, suggests that emotional awareness—rather than more general emotional skills—represents a critical target for intervention.

From this perspective, training programs should not focus exclusively on broad constructs such as emotional intelligence, but should specifically address the ability to identify, differentiate, and verbalize emotional states. Difficulties in these processes, as reflected in elevated DIF scores, may limit students’ capacity to engage in effective emotion regulation and interpersonal communication.

Intervention studies indicate that programs targeting emotion recognition and regulation can improve psychological adjustment and reduce distress among nursing students [19]. Building on the present findings, such interventions should be designed to explicitly strengthen emotional awareness as a foundational process.

In practical terms, these strategies could be implemented through the integration of structured modules within existing curricula. For example, reflective practice sessions could be incorporated into clinical training, requiring students to systematically describe and label their emotional experiences following patient interactions. Similarly, simulation-based learning could include guided debriefing phases specifically focused on identifying emotional responses and linking them to clinical situations.

Potential educational strategies include:

• Structured reflective practices aimed at enhancing the recognition and verbalization of emotional experiences, particularly in relation to clinically challenging situations.
• Targeted assessment tools designed to differentiate components of emotional functioning (e.g., emotional awareness vs. regulation), allowing more specific feedback and monitoring of progress.
• Simulation-based training integrating emotional processing tasks, with facilitated discussion to promote awareness of internal states and interpersonal dynamics.

By explicitly targeting emotional awareness deficits—particularly those captured by the DIF dimension—these interventions are expected to improve students’ ability to recognize and articulate emotions, which in turn may enhance emotion regulation capacities, reduce vulnerability to stress, and support more effective therapeutic communication.

In particular, the DIF dimension directly reflects the ability to identify internal emotional states, making it a specific and measurable target for these interventions.

Finally, brief standardized assessment tools (e.g., repeated TAS-20 subscale monitoring or short emotional awareness checklists) could be used longitudinally to track changes over time and provide individualized feedback to students.

Overall, linking the observed patterns of alexithymia to specific educational strategies allows for a more coherent translation of empirical findings into practice, strengthening the relevance of the study for nursing education and training.

For example, reflective practice could be operationalized through structured emotional journaling sessions integrated into clinical training. After each clinical shift, students could be required to describe a specific interaction, identify the emotions experienced, and label them using predefined emotional categories. These reflections could then be discussed in small-group supervision sessions guided by trained facilitators, promoting both emotional awareness and verbalization.

Similarly, simulation-based training could incorporate explicit emotional processing tasks during debriefing. In addition to discussing clinical decisions, students could be asked targeted questions such as: “What emotion did you experience in that moment?” “How did it influence your behavior?”, and “Were you able to identify it clearly?” This structured approach would allow emotional awareness to be systematically trained rather than implicitly assumed.

5. Conclusions

The present study identified a substantial proportion of nursing students exhibiting elevated alexithymic traits, particularly in relation to difficulties in identifying and describing emotions. While no significant differences were observed across gender or academic year, the overall levels of alexithymia suggest that emotional processing difficulties may be a relevant characteristic within this population.

Rather than interpreting these findings solely in terms of generalized emotional deficits, they should be understood within a more specific framework of impaired emotional awareness. This perspective allows for a clearer distinction between related constructs and provides a more precise basis for both interpretation and intervention.

The absence of significant differences across academic progression suggests that these difficulties may not spontaneously improve with training, highlighting the need for targeted educational strategies. In particular, interventions aimed at enhancing emotional awareness and emotional labelling may represent a crucial step in supporting the development of more adaptive emotional functioning.

Overall, integrating theoretically grounded emotional training into nursing education may help foster more reflective, resilient, and relationally competent healthcare professionals.

6. Limitations

Several limitations should be considered when interpreting the findings of this study.

First, the use of a non-probability convenience sample limits the generalizability of the results. Although the multicenter design enhances sample heterogeneity, the findings should be interpreted with caution and cannot be assumed to represent the broader population of Italian nursing students.

Second, the gender distribution of the sample was markedly unbalanced, with a predominance of female participants. This asymmetry may have reduced the reliability of gender comparisons and limited the ability to detect potential differences.

Third, the cross-sectional design does not allow for conclusions regarding changes over time. In particular, the absence of differences across academic years should not be interpreted as evidence of stability in emotional functioning, as longitudinal data would be required to confirm this pattern.

Finally, the study did not include additional psychological variables such as stress, anxiety, depression, or burnout. This limits the possibility of situating alexithymia within a broader psychological context and constrains the interpretation of its potential impact on students’ well-being and professional development.

Taken together, these limitations suggest that the present findings should be interpreted as exploratory and highlight the need for future research employing longitudinal designs, more balanced samples, and a wider range of psychological measures.

Furthermore, the absence of confidence intervals limits the precision of the estimated effects and should be addressed in future research.