Alexithymia


Alexithymia, also called emotional blindness, is a neuropsychological phenomenon characterized by difficulties processing or describing one's emotions.
Alexithymia occurs in approximately 10% of the population and often co-occurs with various mental or neurodevelopmental disorders. It is often associated with difficulties in attachment and interpersonal relations.

Etymology

The term alexithymia was introduced by psychotherapists John Case Nemiah and Peter Sifneos in 1970 to describe a particular psychological phenomenon. The word is formed by combining the alpha privative prefix ἀ- with λέξις and θῡμός in a way that is like "dyslexia".
In its literal sense, alexithymia signifies the "inability to describe feelings correctly". People who exhibit alexithymic traits or characteristics are commonly referred to as alexithymics or alexithymiacs.

Classification

, scholars have not reached a consensus about the classification of alexithymia. Both the DSM-5 and the ICD-11 classify alexithymia as neither a symptom nor a mental disorder. Cognitive behavioral and psychoanalytic theorists have proposed conceptualizations, including categorical signs and symptoms of alexithymia.

Cognitive behavioral model

The cognitive behavioral model, also known as the attention-appraisal model, proposes three components:
  1. difficulty identifying one's own feelings
  2. difficulty describing one's own feelings
  3. externally oriented thinking characterized by a tendency to not focus attention on emotions.

    Psychoanalytic model

The psychoanalytic model suggests four components:
  1. difficulty identifying one's own feelings
  2. difficulty describing one's own feelings
  3. externally oriented thinking
  4. constricted imaginal processes characterized by infrequent daydreaming
In the psychoanalytic model, constricted imaginal processes does not correlate with other components of alexithymia. Such findings have led to an ongoing debate in the field about whether IMP is a component of alexithymia. As an example, in 2017, Preece and colleagues introduced the attention-appraisal model of alexithymia, where they proposed removing IMP from the definition. In the same paper, they suggested that alexithymia should consist of DIF, DDF, and EOT, as all three are specific to deficits in emotion processing. While regarding the inclusion or exclusion of IMP, there are alexithymia core differences between the psychoanalytic and cognitive-behavioral models. Whereas psychoanalytic formulations tend to continue to place importance on IMP, the attention-appraisal model excludes IMP from the construct. In practice, since the constricted imaginal processes items were removed from earlier versions of the TAS-20 in the 1990s, the most used alexithymia assessment tools have only assessed the construct in terms of DIF, DDF, and EOT.
In terms of the relevance of alexithymic deficits for the processing of both negative emotions and positive emotions, the Perth Alexithymia Questionnaire was the only alexithymia measure that enables valence-specific assessments of alexithymia across both negative and positive emotions according to a report published in 2023. As of 2023, the PAQ has highlighted that alexithymic deficits in emotion processing often do extend across both negative and positive emotions, although people typically report more difficulties for negative emotions. Such findings of valence-specific effects in alexithymia are also supported by brain imaging studies.
Studies have reported that the prevalence rate of high alexithymia is less than 10% of the population. 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 some males have with "describing feelings", but not by difficulties in "identifying feelings", in which males and females show similar abilities. Work with the PAQ has suggested that the alexithymia construct manifests similarly across different cultural groups and ages.
Psychologist R. Michael Bagby and psychiatrist Graeme J. Taylor have argued that the alexithymia construct is inversely related to the concepts of psychological mindedness and emotional intelligence and there is "strong empirical support for alexithymia being a stable personality trait rather than just a consequence of psychological distress".
Difficulty in recognizing and discussing emotions may manifest at subclinical levels in men who conform to specific cultural norms of masculinity, such as the belief that sadness is a feminine emotion. This condition, known as normative male alexithymia, can be present regardless of sex.

Assessment

Alexithymia is most commonly assessed using self-report questionnaires, such as the Perth Alexithymia Questionnaire or the 20-item Toronto Alexithymia Scale. These tools assess the DIF, DDF, and EOT components of alexithymia. Studies that have directly compared these measures have consistently found the PAQ to be the best performing psychometrically, with strong evidence for it providing a comprehensive and reliable alexithymia profile. The PAQ is therefore often regarded as the contemporary gold standard alexithymia assessment tool. For example, the PAQ is the only alexithymia measure that has been successfully validated for use with autistic people. The TAS-20, introduced in 1994, is still a widely used measure for alexithymia. However, studies after 1994 have highlighted a number of validity and reliability concerns with the TAS-20, such as parts of the measure having low reliability, and parts being confounded by how distressed respondents currently are.
Several observer-rated or interview-based measures of alexithymia also exist, but to date, they have been rarely used in research or clinical settings due to long administration times.

Signs and symptoms

Typical deficiencies typically include problems identifying, processing, describing, and working with one's own feelings, often marked by:
  • a lack of understanding of the feelings of others
  • having difficulty distinguishing between feelings and the bodily sensations of emotional arousal
  • confusion of physical sensations often associated with emotions
  • concrete, realistic, logical thinking, often to the exclusion of emotional responses to problems.
Some alexithymic individuals may appear to contradict the above-mentioned characteristics because they can experience chronic dysphoria or manifest outbursts of crying or rage. However, questioning usually reveals that they are quite incapable of describing their feelings or appear confused by questions inquiring about the specific feeling.
According to Henry Krystal, individuals exhibiting alexithymia think in an operative way and may appear to be super-adjusted to reality. However, in psychotherapy, a cognitive disturbance becomes apparent as patients tend to recount trivial, chronologically ordered actions, reactions, and events of daily life with monotonous detail. In general, these individuals can, but not always, 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.
A common misconception about alexithymia is that affected individuals 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 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. The core issue is that people with alexithymia have poorly differentiated emotions, limiting their ability to distinguish and describe them to others. This contributes to the sense of emotional detachment from themselves and difficulty connecting with others, making alexithymia negatively associated with life satisfaction even when depression and other confounding factors are controlled for.

Associated conditions

Alexithymia frequently co-occurs with other disorders. Research indicates that alexithymia overlaps with 50% to 80% of the autistic population, and there is also overlap with sleep disorders, with more overlapping conditions described further below.
In a 2004 study that used the TAS-20, 85% of the adults with ASD fell into the "impaired" category and almost half fell into the "severely impaired" category; in contrast, among the adult control population only 17% were "impaired", and none were "severely impaired". Fitzgerald & Bellgrove pointed out that, "Like alexithymia, Asperger's syndrome is also characterised by core disturbances in speech and language and social relationships". Hill & Berthoz agreed with Fitzgerald & Bellgrove 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 etiology, and similar social skills deficits. The exact nature of the overlap is uncertain. Alexithymic traits in AS may be linked to clinical depression or anxiety; the mediating factors are unknown and it is possible that alexithymia predisposes to anxiety. As an example of this, people with alexithymia are more likely to self-harm in a non-suicidal way. On the other hand, while the total alexithymia score as well as the difficulty in identifying feelings and externally oriented thinking factors are found to be significantly associated with ADHD, and while the total alexithymia score, the difficulty in identifying feelings, and the difficulty in describing feelings factors are also significantly associated with symptoms of hyperactivity and impulsivity, there is no significant relationship between alexithymia and inattentiveness.
There are many more psychiatric and personality disorders that overlap with alexithymia:
Higher levels of alexithymia among mothers with interpersonal violence-related PTSD were found in one study to have proportionally less caregiving sensitivity. This latter study suggested that when treating adult PTSD patients who are parents, alexithymia should be assessed and addressed also with attention to the parent-child relationship and the child's social-emotional development. Specifically, the traits of alexithymia particularly overlap with the schizoid, avoidant, dependent and schizotypal personality disorders, substance use disorders, some anxiety disorders and sexual disorders as well as certain physical illnesses, such as hypertension, inflammatory bowel disease, diabetes, and functional dyspepsia. Alexithymia is further linked with disorders such as migraine headaches, lower back pain, irritable bowel syndrome, asthma, nausea, allergies and fibromyalgia.
People with alexithymia are likely to discharge tension coming from unpleasant emotional states through impulsive behaviors. Some of these include: binge eating, substance abuse, perverse sexual behavior or anorexia nervosa. The failure to regulate emotions cognitively might result in prolonged elevations of the autonomic nervous system and neuroendocrine systems, which can lead to somatic diseases. People with alexithymia also show a limited ability to experience positive emotions leading Krystal and Sifneos to describe many of these individuals as anhedonic.
Alexisomia is a clinical concept that refers to the difficulty in the awareness and expression of somatic, or bodily, sensations. The concept was first proposed in 1979 by Yujiro Ikemi when he observed characteristics of both alexithymia and alexisomia in patients with psychosomatic diseases.