Motivation and emotion/Book/2015/Alexithymia

Alexithymia:
What is alexithymia, why does it matter, and what can be done about it?

Overview

Key Learning Concepts

The overall aim of the chapter is to provide information about the following key concepts:

Alexithymia as a primary or secondary personality trait and its causes.
Diagnosing alexithymia and the validity and reliability of current assessment measures.
The importance of understanding emotions and the effect that alexithymic traits have on an individuals' well-being.
Management and treatment options for individuals with alexithymia.

Once you have read this chapter please try the Quick Quiz to test your understanding of these central concepts.

We’ve all had times when we wished we could shut our emotions off as it would be a nice reprieve from feeling sadness, grief or anger. However, most people would agree that acknowledging and processing these negative emotions is often the best way to be free of them. For people with alexithymia this is not possible, as they are unable to even identify the emotions they are feeling. In fact, it is more likely that they acknowledge the physical manifestations of their emotions e.g. muscles tensing when frustrated (Guttman & Laporte, 2002).

While for some this may seem like it would be beneficial, understanding and interpreting our emotions is actually important to overall well-being (Lumley, Stettner & Wehmer, 1996). Due to this, individuals with alexithymia often have trouble establishing meaningful interpersonal relationships and are at increased risk of poor health (Koven & Thomas, 2010). As Plato (n.d.) famously said, emotions are an essential component of human behaviour.

"Human behaviour flows from three main sources: desire, emotion and knowledge". (Plato, n.d.)

What is alexithymia?

Alexithymia is a personality trait in which an individual is unable to identify and describe the emotions they are feeling (Sifneos, 1973). Trait theory is used in personality research to identify patterns of behaviour that remain stable over time and influence an individuals actions (Swart, Kortekaas & Aleman, 2009). Research by Picardi, Toni and Caroppo (2005) identified alexithymia as a relatively stable dimensional trait, however the severity of alexithymic traits will vary from person to person. Various assessment techniques are utilised to determine where an individual falls on the alexithymia spectrum (Taylor, Bagby & Parker, 2003). Bagby et al. (2009) believe that trait based alexithymia occurs in approximately ten percent of the general population. Yet, not all instances of alexithymia are the result of a stable personality trait. In some cases it can be caused by a specific situation which is known as state alexithymia (Martínez-Sánchez, Ato-García & Ortiz-Soria, 2003). State based alexithymia only occurs for a particular period of time and is most common when co-occurring with another medical disorder (Bagby et al., 2009). These two subsets of alexithymia are also referred to as primary (trait) and secondary (state) causes (Picard et al., 2005).

Alexithymic traits

The majority of people who experience alexithymia have little to no functional awareness of their own emotions and struggle to comprehend many standard emotions in other people (Humphreys, Wood & Parker, 2009). Five key traits were identified by Sifneos (1973) as part of the alexithymia personality construct:

Figure 1. People with Alexithymia often have trouble recognising and expressing their emotions (Sifneos, 1973).

1. Difficulty identifying feelings.

2. Difficulty describing feelings.

3. Difficulty distinguishing between feelings and bodily sensations of arousal.

4. A poor fantasy life

5. An externally oriented cognitive style

Further research has found that individuals with alexithymic traits are often unable to identify and understand the cause of emotion in others (Humphreys et al., 2008). They struggle to recognise facial cues and often have difficulty in creating meaningful interpersonal relationships. Additionally, individuals with alexithymia have a limited ability for creative and imaginative thinking, are unable to determine the source of somatic pain and display logical and concrete thinking patterns (Swart et al., 2009).

Dimensions of alexithymia

It has been theorised that there are two distinct dimensions of alexithymia (Bermond et al., 2007). The table below provides further information:

Table 1

Differences in the cognitive and affective dimensions of alexithymia.

Dimension	What does this mean?	Characteristics	Relevant Studies
Cognitive	The absence of cognition accompanying an emotion indicates that there is an absence in the "thinking" component of self-regulating emotions (Swart et al., 2009)	Cognitive deficits in emotional awareness are characterised by a low ability to interpret, analyse and verbalise emotional reactions (Bermond et al., 2007).	A study conducted by Xiong-Zhao, Xiao-Yan, and Ying (2006) using the Wisconsin Card Sorting Test found that as the degree of alexithymic traits increased in an individual their cognitive control or executive functioning skills decreased. These findings were supported by Koven and Thomas (2010) who established that cognitive tasks such as the ability to plan and use working memory are negatively correlated with emotional clarity. These deficits in executive functioning are likely due to the inability to label and understand emotions when completing tasks (Koven & Thomas, 2010).
Affective	The second dimension is affect based and involves a deficit in the ability to process emotional stimuli and is the "experiencing" component of emotion (Swart et al., 2009).	Affective deficits in emotions are characterised by the inability to react to emotional situations and distinguish bodily sensations from feelings (Swart et al., 2009).	Studies have indicated that individuals with high level alexithymia often have trouble producing facial expressions and recognising them in other people (Jessimer & Markham, 1997). The right hemisphere is essential to recognising facial expression and has been identified as dysfunctional in individuals with alexithymia (Goerlich-Dobre, Votinov, Habel, Pripfl & Lamm, 2015).

What causes alexithymia?

Figure 2. Lack of expressiveness in the family unit can lead to alexithymia (Kench & Irwin, 2000).

Environmental theories

It has been proposed that environmental factors in infancy or childhood influence the chance of exhibiting alexithymic traits (Kench & Irwin, 2000). Low expressiveness was found to be predictive of a high level of alexithymia with Kench and Irwin (2000) positing that the ability to express emotions atrophies as it is not being encouraged. Individuals who experienced neglect or abuse throughout their childhood are also more likely to experience alexithymia (Guttman, & Laporte, 2002). A 2013 study by Aust, Härtwig, Heuser and Bajbouj found that early emotional neglect was positively correlated with instances of alexithymia. Their study also identified a trend in high alexithymic patients experiencing increased emotional dysfunction. It is likely that the absence of positive emotional role models in childhood resulted in an inability to comprehend and express emotions (Aust et al., 2013).

Neurological theories

Neurological theories of alexithymia suggest that the inability to regulate emotions is caused by disturbances in neural pathways (Henry, Phillips, Crawford, Theodorou, & Summers, 2006). Alexithymia has been linked to abnormalities in the right hemisphere, where emotions are identified and formed. As the left hemisphere is primarily responsible for language if the right hemisphere is unable to establish a pathway any emotions being experience will not be verbalised (Jessimer, & Markham, 1997). fMRI images have been used to support this theory with Goerlich-Dobre et al. (2015) identifying unusually thick connections in the neural bridge of individuals with alexithymia. This phenomena means that it is more difficult for messages to pass across the hemispheres.

Additionally, the different dimensions of alexithymia can also be supported using neurological theories. Individuals with predominate cognitive deficits displayed a smaller right amygdala and hippocampus, while affect deficits resulted in volume reduction of the cingulate cortex (Goerlich-Dobre, 2015). Research has also found that patients who have experienced a Traumatic Brain Injury (TBI) have a greater chance of displaying alexithymic characteristics (Henry et al., 2006) further supporting the notion that brain function plays vital role in alexithymia.

Comorbidity with other medical disorders

Alexithymia can also manifest as a consequence of other medical and psychiatric disorders. The table below provides further information:

Table 2

Alexithymia and comorbidity in other medical disorders

Disorder	Relation to Alexithymia
Depression Figure 3. Alexithymia is associated with an increase in depressive symptoms (Bamonti et al., 2010)	High levels of alexithymia are found in patients with depressive disorders. Research has shown that individuals suffering from both depression and alexithymia have increased somatic symtoms, suicidal ideation, and respond less well to antidepressant medications (Vanheule, Desmet, Verhaeghe & Bogaerts, 2007). It has also been suggested that trait based alexithymia can play a role in the cause of depression (Bamonti et al., 2010). Individuals with alexithymia report that they have lower instances of relationship intimacy and satisfaction than the general population. This lack of interpersonal relationships can also hinder the treatment of depression, as there are no support networks in place (Vanheule et al., 2007)
Autism Spectrum Disorders (ASD) Figure 4. ASD Awareness Ribbon - Alexithymia occurs in over 50% of ASD patients (Bird et al., 2010)	Most commonly, individuals with Aspergers Syndrome display increased instances of alexithymic personality traits. It has been estimated that over 50% of ASD sufferers also have alexithymia and alexithymia occurs more regularly in ASD populations (Bird, Silani, Brindley, White, Frith and Singer, 2010). There is a clear overlap in alexithymia and autism symptoms, for example Aspergers is characterised by a disinterest in interpersonal relationships and factual based thinking styles (Bird et al., 2010). However, a study by Bird et al., (2010) found that it is alexithymic not autistic traits that have an impact on an individuals ability to demonstrate affective empathy. This indicates that alexithymic traits may influence the difficulty in processing emotions experienced by individuals with ASD .

How is alexithymia diagnosed?

The most common assessments of alexithymia are completed using self-report measures that look to identify the prevalence of alexithymic traits in an individual (Taylor et al., 2003).

Figure 5. The 20-Item Toronto Alexithymia Scale (TAS-20) is often used to determine if a patient displays the characteristics of Alexithymia (Taylor et al., 2003).

The 20-Item toronto alexithymia scale (TAS-20)

The TAS-20 is the most widely used assessment model and is a self-report instrument consisting of 20 items to be rated on a five-point Likert Scale (Taylor et al., 2003). The TAS-20 is primarily focused on the cognitive dimensions of alexithymia and measures three sub-scales:

1. Difficulty Identifying Feelings (DIF) e.g. "I often don't know why I'm happy".

2. Difficulty Describing Feelings (DDF) e.g. "I find it hard to describe how I am feeling to other people".

3. Externally Orientated Thinking (EOT) e.g. "I prefer to talk to people about their daily activities rather than their feelings" (Moriguchi et al., 2006)

Scores on the TAS-20 can range from 20 to 100 with the clinical threshold for alexithymic traits being a score of 61 or more. Extensive research has established the reliability and construct validity of the TAS-20 (Moriguchi et al., 2006; Taylor et al., 2003) and has it has been successfully translated to 18 different languages. However, the EOT factor has been criticised as no correlation to alexithymia has been found in numerous studies (Bamonti et al., 2010). A study conducted by Bamonti et al. (2010) into the association of depression and alexithymia in older adults found strong support for the impact of both DIF and DID but not EOT. It has been suggested that this is because the TAS-20 is not able to sufficiently measure the affective dimension of alexithymia (Bermond et al., 2007). In order to distinguish the influence of the two dimensions the Bermond-Vorst Alexithymia Questionnaire (BVAQ) was created (Vorst & Bermond, 2001, as cited in Culhane, Morera, Watson & Millsap, 2010).

Bermond-Vorst alexithymia questionnaire (BVAQ)

The BVAQ consists of 40 self-report questions with higher scores indicating higher instance of alexithymia. The BVAQ has five constructs that identify difficulties in the following areas:

1. Verbalising one's own emotional state.

2. Identifying the nature of one's own emotions.

3. Analysing one's own emotional states.

4. Fantasising (degree to which someone is inclined to day-dream and imagine).

5. Emotionalising (degree to which someone is emotionally aroused by events) (Bermond et al., 2007).

A factor analysis conducted by Bermond et al. (2007) established the validity of adding the affect dimension factor of fantasising and emotionalising. Yet, research has found that the BVAQ may not be adaptable to non-anglo populations with a study conducted with hispanic participants finding that it was not as reliable as the TAS-20 (Culhane et al., 2010). Culhane et al. (2010) recommend further evaluation before replacing the TAS-20 with the BVAQ in culturally diverse settings.

Test yourself for alexithymia

Could you have alexithymia?

Please answer true or false to the following questions:

If you received a score of more than two on this quiz then you may display some alexithymic traits. A full assessment can be completed by following this link: [1] (Alexithymia.us, 2015).

What is the impact of alexithymia on an individual?

Lack of creativity and imagination

Individuals with alexithymia show reduced ability for emotionalising and fantasising, which often means that their creative potential and imagination are hindered (Bermond et al., 2007). A study conducted in 2008 found that individuals with high alexithymic traits were less creative than the general population and possessed less mental imagery skills (Czernecka & Szymura, 2008). Often individuals with alexithymia have trouble with spontaneous imagination i.e. ideas that seem to come from no where, but are able to experience controlled imagination by consciously initiating their imagination (Czernecka & Szymura, 2008).

Alexithymia can also lead to impoverished dream recall and dreams being experienced are usually logical and uninteresting (Czernecka & Szymura, 2008). Research shows that individuals who scored high on the TAS-20 factor of EOT were more likely to have shorter dreams and rarely associated their dreams with unconscious motivations. In contrast, individuals with high DIF factor scores displayed greater instances of nightmares and aggressive dreams (Czernecka & Szymura, 2008).

Lack of empathy

Empathy is the ability to understand a person's emotions from their perspective. This includes both affective empathy (the ability to experience another person's emotions) and cognitive empathy (understanding another persons emotional states) similar to the dimensions of alexithymia (Jonason & Krause, 2013). Without the ability to comprehend emotional states in themselves and others, it is difficult for people with alexithymic traits to offer empathetic responses (Grynberg, Luminet, Grèzes, & Berthoz, 2008). Often this means that interpersonal relationships are difficult to establish and maintain (Grynberg et al., 2008).

Case Study
Figure 6. Lack of empathy can cause issues in relationships for people with Alexithymia (Swart et al., 2009). Mike is a 24-year-old male who recently completed the TAS-20 and scored high in the presentation of alexithymic traits. While Mike was relieved to have a better understanding of his inability to identify and express his emotions his alexithymia was having a negative effect in other areas of his life. Mike recently became engaged and was planning his wedding to partner Tasha. Before his diagnosis Mike used preplanned responses when his partner Tasha displayed emotions. Although Tasha was aware of his alexithymia diagnosis she was still upset when Mike was unable to provide empathetic responses to her feelings. Tasha had been especially upset at Mike’s disinterest in planning the wedding and called him a robot. Mike was constantly concerned that he would say the wrong thing or misinterpret Tasha’s emotions. He had been experiencing physical manifestations of this anxiety in the form of grinding his teeth, headaches and shortness of breath. Mike and Tasha decided to attend therapy to see if they could resolve these issues. Mike worked on understanding his physical symptoms as a manifestation of a certain emotion and how to identify this. Meanwhile, Tasha focused on better understanding alexithymia and how she could explain her emotions in terms Mike could comprehend. They decided to postpone their wedding to ensure that their relationship was stable before getting married.

Risk of poor health

Health outcomes for individuals with alexithymia are often poor (Lumley et al., 1996). Somatic symptoms, in which the physical source of the problem is unable to be located are often reported. The inability to regulate emotions can lead to increased periods of physiological distress as the physical sensations associated with emotions are misinterpreted. Individuals with alexithymia report higher instances of hypertenstion, irritable bowel syndrome and anxiety disorders (Lumley et al., 1996). Alexithymia also contributes to poor health outcomes by promoting maladaptive coping mechanisms such as compulsive behaviors (Bamonti et al., 2010). It is likely that this occurs as individuals with alexithymia have no outlet for their emotions and instead express them by focusing on controllable actions (Bamonit et al., 2010).

Want more information?

Listen to Dr. David Purves explain the health impacts of Alexithymia [2] (Purves, 2015).

What are the treatment options for alexithymia?

Figure 7. Creative and mindfulness approaches also work to increase the ability to identify and verbalise emotions (Ogrodniczuk et al., 2011).

Increasing emotional understanding

While there is no cure for trait based alexithymia there are ways that it can be successfully managed. The goal of most treatment options is to increase an individual's ability to identity, understand and express their emotions (Koven & Thomas, 2010). A key part of treatment is teaching individuals with alexithymia to associate their physical symptoms with the corresponding emotion. A bodily map of emotions is often used as a learning tool as it provides a visual reference to which body part is activated when feeling various emotions (Nummenmaa, Glerean, Hari & Hietanen, 2013). Psychotherapy techniques have also proven successful, especially in group settings as they offer clear examples of positive emotional communication. Research by Ogrodniczuk,Piper and Joyce (2011) found that alexithymic traits decline after group therapy and this decrease remains stable after stopping therapy sessions. However, poorer outcomes are experienced by individuals with higher alexithymic traits as they are less open to clinical intervention (Ogrodniczuk et al., 2011).

Oxytocin

Oxytocin treatments have been used in alexithymia patients to increase the ability to process emotional cues and form interpersonal relationships (Quirin et al., 2014). Oxytocin is naturally produced in the human body but levels can be increased by inhaling it through the nose. Oxytocin works to increase an individuals willingness to share painful emotions and also reduces stress by dampening physiological stress-systems (Luminet, Grynberg, Ruzette, & Mikolajczak, 2011). Luminet et al., (2011) found that the benefits of oxytocin treatment are especially pronounced high alexithymic patients. However, it is recommend that oxytocin used in conjunction with psychotherapy to facilitate true emotional awareness (Quirin et al., 2014).

Test your knowledge

Conclusion

Take Home Message

Emotions play an important role in an individual's well-being as they help us to make decisions, understand other people, achieve goals and form emotional attachments (Lumley at al., 1996). Although alexithymia makes it difficult to identify and describe emotions it is not impossible to live a fulfilling life. Individuals with alexithymia should attempt to increase their emotional awareness through therapeutic techniques including taking oxytocin and completing psychotherapy. An understanding and supportive environment is essential to living with alexithymia especially if it is co-morbid with other disorders (Ogrodniczuk et al., 2011). Therefore, it important to establish meaningful interpersonal relationships with people who are aware of the deficits associated with alexithymic traits.

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