Alexithymia, also known as emotional blindness, is distinguished by a cluster of traits concerning emotional awareness and processing. Individuals with alexithymia face significant difficulty identifying feelings and difficulty describing feelings to others.
The condition is marked by a reduced ability to recognize one’s own emotions or those of other people. Additionally, it involves an externally oriented thinking style, which is a focus on external events over internal emotional experiences. This cognitive style can lead to a preference for practical, factual information rather than introspection about emotions.
Prevalence of alexithymia in the general population is estimated to to be approximately 10%. Certain medical conditions, such as chronic pain or cardiovascular diseases, show a higher incidence of alexithymia, with rates varying based on the study population and diagnostic criteria used.
The word alexithymia was coined by psychotherapists John Case Nemiah and Peter Sifneos in 1973. It derives from Ancient Greek words which in their literal sense, mean “no words for emotions.”. This name reflects the difficulty that people with this illness have in recognizing, expressing, and articulating their emotions.
Alexithymia Causes and Contributing Factors
It is unknown what causes alexithymia, but several theories have been proposed.
Early research suggested that people with alexithymia may have an interhemispheric transfer deficit. In this theory, emotional information from the right hemisphere of the brain is not being properly transferred to language regions in the left hemisphere. This can be caused by a decreased corpus callosum, common in psychiatric patients who have experienced severe childhood abuse.
Injury to the brain’s emotional processing centers, like the amygdala or prefrontal cortex, may disrupt one’s ability to process and express emotions effectively. There is a well-documented link between brain injury and subsequent emotional regulation difficulties.
One neuropsychological study published in 1997 suggested that alexithymia could be caused by a malfunction in the right hemisphere of the brain, which is primarily responsible for emotion processing. Another neuropsychological model implies that alexithymia is associated with anterior cingulate brain dysfunction.
Molecular genetic research on alexithymia is limited, although interesting candidates have been identified through studies studying the links between particular genes and alexithymia in both those with psychiatric illnesses and the general population. A study of Japanese males indicated that those with the 5-HTTLPR homozygous long (L) allele performed better on the Toronto Alexithymia Scale.
The 5-HTTLPR region of the serotonin transporter gene controls the transcription of the serotonin transporter, which removes serotonin from the synaptic cleft, and has been extensively examined for its relationship with a variety of psychiatric diseases.
Joyce McDougall, a French psychoanalyst, objected to the significant emphasis on neurophysiological explanations for the genesis and operation of alexithymia, and used the word “disaffectation” to refer to psychogenic alexithymia. According to McDougall, the disaffected individual had “experienced overwhelming emotion that threatened to attack their sense of integrity and identity” at some point, and they used psychological defenses to pulverize and eject all emotional representations from consciousness.
McDougall has also remarked that all children are born unable to define, organize, and communicate about their emotional experiences (the word infans comes from the Latin “not speaking”), and are “by reason of their immaturity inevitably alexithymic”. Based on this, McDougall hypothesized in 1985 that the alexithymic element of an adult personality could be “an extremely arrested and infantile psychic structure”.
Symptoms
Deficiencies often seen in individuals with alexithymia may involve difficulties in recognizing, processing, articulating, and managing their own emotions. These difficulties are frequently accompanied by a lack of empathy towards others’ emotions, confusion between emotions and bodily sensations of arousal, as well as a limited imaginative capacity leading to a scarcity of dreams or fantasies.
Additionally, individuals with alexithymia tend to exhibit a preference for concrete, practical, and logical thinking, often at the expense of emotional considerations when addressing issues. People with this condition often describe their dreams as highly logical and realistic, focusing on mundane activities like grocery shopping or having a meal. Clinical observations indicate that the nature of the dreams themselves, rather than the ability to remember them, is what most accurately reflects the traits of alexithymia.
Some alexithymic people may appear to contradict the aforementioned qualities because they feel persistent dysphoria or have bouts of sobbing or wrath. However, probing frequently indicates that individuals are unable to describe their sentiments or appear perplexed when asked about specific feelings.
Comorbidities
Comorbidity between alexithymia and psychiatric conditions is substantial. Researchers have identified that individuals with alexithymia often exhibit an elevated prevalence of mental health disorders, such as depression, anxiety, and post-traumatic stress disorder (PTSD).
For instance, studies suggest a significant association between alexithymia and depression, where the difficulty in processing and expressing emotions may exacerbate depressive symptoms. Similarly, the link with anxiety points towards impaired emotional regulation contributing to heightened anxiety levels.
Moreover, there is an observed prevalence of alexithymia among those with PTSD, highlighting the potential for alexithymia to impact the processing and recovery from traumatic experiences. The presence of alexithymia in these individuals may impede the ability to benefit fully from therapeutic interventions, as they may struggle to articulate their emotions during treatment.
Studies reveal connections between autism spectrum disorders (ASD) and alexithymia. 85% of the individuals with ASD and nearly half of the adult control group were classified as “impaired” or “severely impaired” in a 2004 study that used the TAS-20; in comparison, just 17% of the adult control group met this criteria.
Certain personality disorders, including schizoid, avoidant, dependent, and schizotypal disorders, substance use disorders, some anxiety disorders, and physical ailments like hypertension, inflammatory bowel disease, diabetes, and functional dyspepsia are associated with alexithymia. Additional conditions that are associated with alexithymia include fibromyalgia, allergies, asthma, nausea, irritable bowel syndrome, and migraine headaches.
Personal and Social Relationships
When people with alexithymia form relationships, they typically portray themselves as either impersonal, domineering, or dependent, “such that the relationship remains superficial.”
This avoidance of emotionally intimate interactions can lead to interpersonal issues. Insufficient “differentiation” between oneself and others has also been noted in alexithymic people. When a person is single, they frequently experience trouble processing interpersonal relationships.
in a 2020 study examining the role of alexithymia in social cognition, individuals exhibited challenges with different components of social cognition, such as recognizing emotional expressions in others. This impairment can contribute to problems with attachment and communication, making it hard for them to respond to the emotional needs of others, thereby straining relationships.
Additionally, traditional notions of masculinity, which often discourage the expression of vulnerability, may further exacerbate such challenges for men with alexithymia. The concept of normative male alexithymia refers to the mild to moderate difficulty in emotional expression often deemed acceptable for men within certain cultures. This societal acceptance is closely linked to traditional masculinity ideals, where emotional stoicism is valued, and vulnerability is often discouraged.
Diagnosis and Testing
The evaluation of alexithymia heavily relies on standardized instruments designed to measure the inability to identify and describe emotions. These tools are critical for research and clinical settings, providing insights into the emotional functioning of individuals.
Standardized scales and assessments include:
- Toronto Alexithymia Scale (TAS-20) Widely recognized as a standard measure, the Toronto Alexithymia Scale operates with a threshold score indicating the presence of alexithymia. This self-report questionnaire discriminates between levels of alexithymia through a set of 20 items, offering a specific and clinically relevant assessment.
- Levels of Emotional Awareness Scale (LEAS) The Levels of Emotional Awareness Scale presents scenarios to respondents, assessing the ability to identify and describe emotions within oneself and in others. It assumes different levels of emotional awareness and provides valuable context for empathetic capacity and emotional processing.
- Observer Alexithymia Scale (OAS) Unlike self-report measures, the Observer Alexithymia Scale is completed by individuals who are familiar with the subject, providing an external evaluation of alexithymic traits. It accounts for a comprehensive view by incorporating the observations of third parties.
Treatment Strategies for Alexithymia
There are currently few effective treatment options for alexithymia, as the area is still in its infancy. The fact that alexithymia co-occurs with other conditions is a major factor affecting treatment.
A skills-based intervention has been shown to be one effective treatment for alexithymia (Mataji Kennedy and John Franklin, 2002).
As part of their treatment strategy, Kennedy and Franklin administered a number of questionnaires, psychodynamic therapies, experiential therapies, and cognitive-behavioral and skills-based treatments. They discovered that following treatment, participants were more aware of their emotional states and usually less hesitant to share their feelings.
Alexithymia can also be effectively treated using mentalization-based treatment, according to research conducted in 2018 by Löf, Clinton, Kaldo, and Rydén. Mentalization is the capacity to comprehend one’s own or other people’s mental states that underlie outward conduct.
Mentalization-based treatment assists patients in separating their inner thoughts and feelings from those of others. Gaining a better knowledge and application of mentalizing skills is the main goal of this relational treatment.
The treatment encouraged affect tolerance and the capacity to think flexibly while expressing intense affect rather than impulsive conduct, and the researchers discovered that all of the patients’ symptoms, including alexithymia, considerably improved.
References:
- Bagby RM, Parker JD, Taylor GJ (1994). The twenty-item Toronto Alexithymia Scale–I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research. 38 (1): 23–32. doi: 10.1016/0022-3999(94)90005-1
- Blaustein JP, Tuber SB (1998). Knowing the Unspeakable. Bulletin of the Menninger Clinic. 62: 351–365
- Di Tella, M., Adenzato, M., Catmur, C., Miti, F., Castelli, L., & Ardito, R. B. (2020). The role of alexithymia in social cognition: Evidence from a non-clinical population. Journal of affective disorders, 273, 482–492
- Hemming L, Haddock G, Shaw J and Pratt D (2019) Alexithymia and Its Associations With Depression, Suicidality, and Aggression: An Overview of the Literature. Front. Psychiatry 10:203. doi: 10.3389/fpsyt.2019.00203
- Hill E, Berthoz S, Frith U (2004). Brief report: cognitive processing of own emotions in individuals with autistic spectrum disorder and in their relatives. Journal of Autism and Developmental Disorders. 34 (2): 229–235. doi:10.1023/B:JADD.0000022613.41399.14
- Hoppe KD, Bogen JE (1977). Alexithymia in twelve commissurotomized patients. Psychotherapy and Psychosomatics. 28 (1–4): 148–155. doi: 10.1159/000287057
- Jessimer M, Markham R (1997). Alexithymia: a right hemisphere dysfunction specific to recognition of certain facial expressions?. Brain and Cognition. 34 (2): 246–258. doi: 10.1006/brcg.1997.0900
- Kennedy M, Franklin J. Skills-based Treatment for Alexithymia: An Exploratory Case Series. Behaviour Change. 2002;19(3):158-171. doi: 10.1375/bech.19.3.158
- Kano M, Mizuno T, Kawano Y, Aoki M, Kanazawa M, Fukudo S (2012). Serotonin transporter gene promoter polymorphism and alexithymia. Neuropsychobiology. 65 (2): 76–82. doi: 10.1159/000329554
- Lane RD, Ahern GL, Schwartz GE, Kaszniak AW (November 1997). Is alexithymia the emotional equivalent of blindsight? Biological Psychiatry. 42 (9): 834–844. doi:10.1016/S0006-3223(97)00050-4
- Lumley, M. A., Stettner, L., & Wehmer, F. (1996). How are alexithymia and physical illness linked? A review and critique of pathways. Journal of Psychosomatic Research, 41(6), 505–518
- McDougall J (1985) Theaters of the Mind: Truth and Illusion on the Psychoanalytic Stage. New York: Basic Books. ISBN 978-0-946960-70-5
- Pandey, R., Saxena, P., & Dubey, A. (2011). Emotion regulation difficulties in alexithymia and mental health. Europe’s Journal of Psychology, 7(4), 604-623
- Samur D, Tops M, Schlinkert C, Quirin M, Cuijpers P, Koole SL (2013). Four decades of research on alexithymia: moving toward clinical applications. Frontiers in Psychology. 4: 861. doi: 10.3389/fpsyg.2013.00861
- Taylor GJ, Bagby RM, Parker JD (1997). Disorders of Affect Regulation: Alexithymia in Medical and Psychiatric Illness. Cambridge: Cambridge University Press. ISBN 978-0-521-45610-4
- von Rad M (1984). Alexithymia and symptom formation. Psychotherapy and Psychosomatics. 42 (1–4): 80–89. doi: 10.1159/000287827