Alexithymia

Alexithymia (pronounced /əˌlɛksəˈθaɪmiə/) from the Greek words λεξις and θυμος (literally "without words for emotions") is a term coined by Peter Sifneos in 1973^[1][2] to describe a state of deficiency in understanding, processing, or describing emotions.

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Classification

Alexithymia is considered to be a personality trait that places individuals at risk for other medical and psychiatric disorders while reducing the likelihood that these individuals will respond to conventional treatments for the other conditions.^[3] Alexithymia is not classified as a mental disorder in the DSM IV. It is a personality trait that varies in severity from person to person. A person's alexithymia score can be measured with questionnaires such as the Toronto Alexithymia Scale (TAS-20), the Bermond-Vorst Alexithymia Questionnaire (BVAQ)^[4] or the Observer Alexithymia Scale (OAS).^[3]

Alexithymia is defined by:^[5]

• (i) difficulty identifying feelings and distinguishing between feelings and the bodily sensations of emotional arousal
• (ii) difficulty describing feelings to other people
• (iii) constricted imaginal processes, as evidenced by a paucity of fantasies
• (iv) a stimulus-bound, externally oriented cognitive style.

In studies of the general population the degree of alexithymia was found to be influenced by age, but not by gender; the rates of alexithymia in healthy controls have been found at 8.3% (2 of 24 persons) 4.7% (2 of 43), 8.9% (16 of 179), and 7% (4 of 56). Thus, several studies have reported that the prevalence rate of alexithymia is less than 10% in healthy controls.^[6] A less common finding suggests that there may be a higher prevalence of alexithymia amongst males than females, which may be accounted for by difficulties they have with 'describing feelings', but not by a difficulty in 'identifying feelings' in which males and females show similar abilities.^[7]

The alexithymia construct is strongly inversely related to the concepts of psychological mindedness^[8] and emotional intelligence^[9][10] and M. Bagby and G. Taylor state that there is "strong empirical support for alexithymia being a stable personality trait rather than just a consequence of psychological distress".^[11] Other opinions differ and can show evidence that it may be state-dependent.^[12]

Bagby and Taylor also suggest that there may be two kinds of alexithymia, 'primary alexithymia' which is an enduring psychological trait which does not alter over time, and 'secondary alexithymia' which is state dependent and disappears after the evoking stressful situation has changed. These two manifestations of alexithymia are otherwise called 'trait' or 'state' alexithymia.^[13]

Typical deficiencies may include problems identifying, describing, and working with one's own feelings, often marked by a lack of understanding of the feelings of others; difficulty distinguishing between feelings and the bodily sensations of emotional arousal;^[1] confusion of physical sensations often associated with emotions; few dreams or fantasies due to restricted imagination; and concrete, realistic, logical thinking, often to the exclusion of emotional responses to problems. Those who have alexithymia also report very logical and realistic dreams, such as going to the store or eating a meal.^[14] Clinical experience suggests it is the structural features of dreams more than the ability to recall them that best characterizes alexithymia.^[1]

Some alexithymic individuals may appear to contradict the above mentioned characteristics because they can experience chronic dysphoria or manifest outbursts of crying or rage.^[15][16][17] However, questioning usually reveals that they are quite incapable of describing their feelings or appear confused by questions inquiring about specifics of feelings.^[5]

According to Henry Krystal, individuals suffering from alexithymia think in an operative way and may appear to be superadjusted to reality. In psychotherapy, however, a cognitive disturbance becomes apparent as the patients tends to recount trivial, chronologically ordered actions, reactions, and events of daily life with monotonous detail.^[18][19] In general, these individuals lack imagination, intuition, empathy, and drive-fulfillment fantasy, especially in relation to objects. Instead, they seem oriented toward things and even treat themselves as robots. These problems seriously limit their responsiveness to psychoanalytic psychotherapy; psychosomatic illness or substance abuse is frequently exacerbated should these individuals enter psychotherapy.^[5]

A common misconception about alexithymia is that victims of this construct are totally unable to express emotions verbally and that they may even fail to acknowledge that they experience emotions. Even before coining the term, Sifneos (1967) noted patients often mentioned things like anxiety or depression. The distinguishing factor was their inability to elaborate beyond a few limited adjectives such as "happy" or "unhappy" when describing these feelings.^[20] The core issue is that alexithymics have poorly differentiated emotions limiting their ability to distinguish and describe them to others.^[1] This contributes to the sense of emotional detachment from themselves and difficulty connecting with others that is typical of the alexithymic's experience.^{[citation needed]}

Relational issues

According to Vanheule, Desmet and Meganck (2006) alexithymia creates interpersonal problems because these individuals avoid emotionally close relationships, or that if they do form relationships with others they tend to position themselves as either dependent or impersonal, "such that the relationship remains superficial."^[21] Inadequate differentiation between self and other by alexithymic individuals has been observed by Blaustein & Tuber (1998) and Taylor et al (1997).^[22]

In a study, a large group of alexithymic individuals completed the 64-item Inventory of Interpersonal problems (IIP-64) which screens for:^[21]

• (a) Domineering/Controlling, indicating difficulties relinquishing control over others;
• (b) Vindictive/Self-Centered behaviour, which describes problems of hostile dominance and the tendency to fight with others;
• (c) Cold/Distant behaviour, which refers to low degrees of affection for and connection with others;
• (d) Socially Inhibited, which assesses the tendency to feel anxious and avoidant in the presence of others;
• (e) Non-Assertiveness, which measures problems in taking initiative in relation to others and coping with social challenges;
• (f) Overly Accommodating, which indicates an excess of friendly submissiveness;
• (g) Self-Sacrificing, which indicates a tendency to affiliate excessively; and
• (h) Intrusive/Needy, which describes problems with friendly dominance.

The study found that alexithymic individuals "had significantly higher scores on all IIP-64 subscales than did the nonclinical sample."^[21]

Chaotic interpersonal relations have also been observed by Sifneos.^[23] Due to the inherent difficulties identifying and describing emotional states in self and others, alexithymia also negatively affects relationship satisfaction between couples.^[24]

In medical and psychiatric illness

Alexithymia frequently co-occurs with other disorders, with a representative prevalence of 85% in autism spectrum disorders,^[25] 40% in posttraumatic stress disorder,^[26] 63% in anorexia nervosa, 56% in bulimia,^[27] 45% in major depressive disorder,^[12] 34% in panic disorder,^[28] and 50% in substance abusers.^[29]

Research indicates that alexithymia overlaps with Asperger syndrome. In a 2004 study, Uta Frith reported an overlap and that at least half of the Asperger syndrome group obtained scores on the Toronto Alexithymia Scale (TAS-20) that would classify them as severely impaired.^[30] Fitzgerald & Bellgrove pointed out that, "Like Alexithymia, Asperger’s syndrome is also characterised by core disturbances in speech and language and social relationships".^[31] Hill & Berthoz agreed with Fitzgerald & Bellgrove (2006) and in response stated that "there is some form of overlap between alexithymia and ASDs". They also pointed to studies that revealed impaired Theory of Mind skill in alexithymia, neuroanatomical evidence pointing to a shared aetiology and similar social skills deficits.^[32] The exact nature of the overlap is uncertain. Alexithymic traits in AS may be linked to depression or anxiety;^[30] the mediating factors are unknown and it is possible that alexithymia predisposes to anxiety.^[33]

Alexithymia involves higher risk of developing certain personality disorders,^[34] and is correlated with particular illnesses, such as hypertension,^[35] inflammatory bowel disease,^[36] functional dyspepsia,^[37] sexual disorders,^[38] substance use disorders,^[39][40] and some anxiety disorders.^[41] Alexithymia is further linked with psychosomatic disorders such as migraine headaches, lower back pain, irritable bowel syndrome, asthma, nausea, allergy, and fibromyalgia.^[42]

An inability to modulate emotions is a possibility in explaining why some alexithymics are prone to discharge tension arising from unpleasant emotional states through impulsive acts or compulsive behaviors such as binge eating,^[43] substance abuse,^[44] perverse sexual behavior, or the self-starvation of anorexia nervosa.^[43] The failure to regulate emotions cognitively might result in prolonged elevations of the autonomic nervous system (ANS) and neuroendocrine systems which can lead to somatic diseases.^[42] Alexithymics also show a limited ability to experience positive emotions leading Krystal (1988) and Sifneos (1987) to describe many of these individuals as anhedonic.^[2]

Etiology

According to French psychoanalyst Joyce McDougall all infants are born unable to identify, organize, and speak about their emotional experiences (the word infans is from the Latin "not speaking"), and are "by reason of their immaturity inevitably alexithymic".^[45] Based on this fact McDougall writes, "Might it not be supposed that the alexithymic part of an adult personality is an extremely arrested and infantile psychic structure?"^[45]

It is unclear what causes alexithymia. Some neuropsychological studies indicate that alexithymia may be due to a disturbance to the right hemisphere of the brain, which is largely responsible for processing emotions.^[46] Other studies show evidence that there may be an interhemispheric transfer deficit among alexithymics; that is, the emotional information from the right hemisphere is not being properly transferred to the language regions in the left hemisphere, as can be caused by a decreased corpus callosum, often present in psychiatric patients who have suffered severe childhood abuse.^[47] In addition, another neuropsychological model suggests that alexithymia may be related to a dysfunction of the anterior cingulate cortex.^[48] These studies have some shortcomings, however, and the empirical evidence about the causes of alexithymia remain inconclusive.^[49]

Joyce McDougall objected to the strong focus by clinicians on neurophysiological at the expense of psychological explanations for the genesis and operation of alexithymia, and introduced the alternative term 'disaffectation' to stand for psychogenic alexithymia.^[50] For McDougall, the disaffected individual had at some point "experienced overwhelming emotion that threatened to attack their sense of integrity and identity," to which they applied psychological defenses to pulverize and eject all emotional representations from consciousness.^[51]

Although physiological effects are important to determine, the first language of an infant is nonverbal facial expressions. The mother's emotional state is important for determining how any child might develop. Neglect or indifference to varying changes in a child's facial expressions without proper feedback can promote an invalidation of the facial expressions manifested by the child. The parent's ability to reflect self-awareness to the child is another important factor. If the adult is incapable of recognizing and distinguishing emotional expressions in the child, it can influence the child's capacity to understand emotional expressions.^[1]

Although environmental, neurological, and genetic factors are each involved, the role of genetic and environmental factors for developing alexithymia is still unclear.^[52] The results from a large population-based sample of Danish twins suggest that genetic factors have a noticeable and similar impact on all facets of alexithymia. While the results suggested a moderate influence of shared environmental factors, results are in concordance with the general finding that environmental influences on most psychological traits are primarily of the nonshared rather than the shared type.^[53]

See also

• Amplification (psychology)
• Psychological mindedness
• Emotional intelligence
• Disaffectation

References

• Bar-On, Reuven; Parker, James DA (2000). The Handbook of Emotional Intelligence: Theory, Development, Assessment, and Application at Home, School, and in the Workplace. San Francisco, California: Jossey-Bass. ISBN 0787949841. 
• Krystal, H (1988). Integration and Self Healing: Affect, Trauma, Alexithymia. Hillsdale, NJ: The Analytic Press. ISBN 0881630705. 
• Linden W, Wen F, Paulhaus DL (1994). Measuring alexithymia: reliability, validity, and prevalence. In: J. Butcher, C. Spielberger (Eds.). Advances in Personality Assessment. Hillsdale, NJ: Lawrence Erlbaum Associates.
• McDougall, J (1989). Theaters of the Body: A Psychoanalytic Approach to Psychosomatic Illness, Norton.
• McDougall, J (1985). Theatres of the Mind: Truth and Illusion on the Psychoanalytic Stage. New York: Basic Books. 
• Nemiah CJ, Freyberger H, Sifneos PE, "Alexithymia: A View of the Psychosomatic Process" in O.W. Hill (1970) (ed), Modern Trends in Psychosomatic Medicine, Vol 2.
• Taylor, Graeme J; Bagby, R. Michael and Parker, James DA (1997). Disorders of Affect Regulation: Alexithymia in Medical and Psychiatric Illness. Cambridge: Cambridge University Pres. ISBN 052145610X. 
• ^ Taylor GJ & Taylor HS (1997). Alexithymia. In M. McCallum & W.E. Piper (Eds.) Psychological mindedness: A contemporary understanding. Munich: Lawrence Erlbaum Associates

Notes