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The Alexithymia FAQ

Version 1.1

Jan 23, 2003 (originally posted Jan 16, 2003)

By Hal, with sincere thanks to Triton & Anne. Thanks also to Jan & Trucker for providing additional questions.

This FAQ is at an early stage of development. It is designed to serve as a introduction. I welcome any contributions or suggestions for revisions. If you can think of any other pertinent questions, please notify me—or better still, post them to the group—and I will try to include an answer here in due course.

There are differing opinions on many fundamental points, and it is difficult to say much of substance without contradicting some published views. I have adhered to what I see as the primary 'psychiatric' sense of alexithymia as represented on the Alexithymia chatsite, while duly acknowledging the psychometric alternative.

At this early stage, the contents of the FAQ are liable to change significantly and frequently. I may include supporting quotations in a later revision. Feedback welcome.

THE ALEXITHYMIA FAQ


What is alexithymia?

Loosely speaking, alexithymia is the inability to talk about feelings due to a lack of emotional awareness. Alexithymics are typically unable to identify, understand or describe their own emotions. (NB: this is a very general description and should not be cited as an authoritative definition.)

The term was coined from the Greek a- (prefix meaning "lack"), lexis ("word") and thymos ("feelings"), and hence can be read literally as "a lack of words for feelings". However it is wrong and potentially misleading to say that this constitutes its meaning, because the term is a lexeme: its meaning is given by its definition and is not constructed from the sum of its components. The term means the syndrome described in the literature and not simply an absence of emotion words.

Two conceptions of alexithymia

There are two common conceptions of alexithymia in the academic literature—psychiatric (in medical literature) and psychometric (in psychological literature).

The original concept emerged in the context of psychiatry and psychosomatic medicine and conforms to the standard "medical model" of psychopathologies common in psychiatry. This FAQ and the Alexithymia chatsite both employ the term in this original sense.

The alternative sense of alexithymia in psychometric psychology conceives it as a dimensional personality trait. It implies a continuous range of abilities and is not necessarily indicative of a disorder. The difference in definition is subtle but important.

Both senses have strengths and weaknesses and both have justifiable claims to legitimacy. Naturally this duality of meaning leads to considerable confusion. Most theoretical discussions of alexithymia seem to imply the psychiatric model, but most of the tests adopt the psychometric model. The confusion is often apparent within single publications. For example, many studies identify an assumption from the psychiatric literature, then examine the corresponding hypothesis by selecting subjects with the psychometric questionnaire and conclude that the hypothesis is not supported; however the psychometric test has implicitly redefined the construct and widened its range of reference. Accordingly, it is questionable whether the results of many empirical studies have a direct bearing on the psychiatric conception of alexithymia as outlined in this FAQ.


What is it not?

There are many popular misconceptions about alexithymia. Notably, web searches on the term return links to radically different definitions and descriptions (try it!). Many erroneous definitions confuse alexithymia with a lack of emotion or emotional expression.

For the record, alexithymia should not be confused with:

Sociopathy (a lack of concern for others)
Stoicism (deliberate resistance of emotional impulses) or
Apathy (a lack of emotional reactivity or motivation)
Emotional repression (subconscious but motivated denial of emotion).

The reasons are given here.

Alexithymia also should not be confused with the '(stereo-)typical' male inability to express emotions. See the question "Are all men partially alexithymic?" below.


Why haven't I heard of alexithymia before?

It hasn't been well publicised. Most clinical professionals—family doctors, psychologists and psychiatrists—know little or nothing about alexithymia. Some take a disparaging view, arguing that the construct is poorly defined, doctrine-dependent or of no practical use in psychiatry.

Nevertheless, hundreds of articles have been published in the specialist medical journals. There have been occasional mentions of the construct in popular science books (for example Daniel Goleman's Emotional Intelligence, or Rita Carter's Mapping the Mind).


How do I tell if I'm alexithymic?

If you have a marked deficiency in emotional understanding, there will be various clues evident in everyday life. For example, you might:

find it difficult to talk about your own emotions;
be perceived by others as excessively logical, or unsentimental without being unfriendly;
be perplexed by other people's emotional reactions;
give pedantic and long-winded answers to practical questions;
rarely daydream or fantasise about personal prospects;
have a subdued reaction to art, literature or music;
make personal decisions according to principles rather than feelings;
suffer occasional inexplicable physiological disturbances such as palpitations, stomach ache, or hot flushes.

These features are offered only as guides for prompting further investigation and assessment. They cannot support a diagnosis.


Where did the term originate?

During the 1950s and 60s some psychiatrists noted that a large proportion of patients with psychosomatic complaints had extreme difficulty talking about their emotions. These patients had other characteristics in common, including a stiff posture, a focus on functional details and a barren fantasy life. In 1972 Peter Sifneos introduced the term alexithymia to refer to this bundle of characteristics.


What are the key features of the alexithymia syndrome?

Difficulty identifying different types of feelings
Difficulty distinguishing between emotional feelings and bodily feelings
Limited understanding of what caused the feelings
Difficulty verbalising feelings
Limited emotional content in the imagination
Functional style of thinking
Lack of enjoyment and pleasure-seeking
Stiff, wooden posture

Please note this is not a checklist. There is still some debate about which of these characteristics are definitional, and which are incidental.


How is it formally assessed?

In the clinical test, a consultant psychiatrist assesses and evaluates a person's responses to key questions during interview. There are various test questionnaires. The Beth Israel Questionnaire is still the benchmark for the psychiatric version of the concept. The assessor should have formal psychiatric training in affective disorders. The ratings are subjective; hence it is unsuitable for the purposes of objective scientific research.

The 20-item Toronto Alexithymia Scale (TAS-20) self-report questionnaire is by far the most popular measure for use in psychological studies because it is a well-validated and consistent data-collection device. Although people who score highly on the scale are more likely to exhibit the psychiatric syndrome, the questionnaire does not constitute a diagnostic tool.

The TAS-20 questionnaire, together with supporting materials, can be ordered for a 35 US dollar copyright fee from http://www.gtaylorpsychiatry.org/research.htm.


Is it a disorder, a condition, a syndrome, an illness, a personality trait, a thinking style, or a neurotic defence?

Alexithymia is conceived in this context as a syndrome (i.e. a cluster of characteristics), although for convenience the term is often used to refer to the underlying psychological condition or disorder. In this respect it is analogous to dyslexia. Both are conceived as syndromes indicative of (hypothetical) psychological deficits. They may be loosely described as psychological disorders but neither constitutes an illness in the normal sense of the term.

Most of the recent research literature in psychology uses the dimensional personality trait version of the concept. It does not view alexithymia principally as a syndrome, although high alexithymia scores are likely to correlate with the psychiatric syndrome described by Sifneos et al.

These two conceptions are arguably alternative ways of conceiving essentially the same phenomenon, but they are semantically distinct and must not be confused. Interpreting statements about one in terms of the other leads to misunderstandings and confounds scientific method. There are reasons to believe this has been happening in some recent empirical studies.

Be wary of defining alexithymia in terms of causal theories. Despite the strong evidence for developmental or psychodynamic causes, alexithymia should not be defined as a developmental or psychodynamic condition. Similarly, it is inappropriate to describe alexithymia as a thinking style or a neurotic defence. Defining it in causal terms eclipses alternative theories and prejudices empirical research.


Is it psychological or neurological?

This is a common question levied at psychiatric syndromes, usually with the aim of attributing responsibility or identifying suitable therapies.

A distinction has sometimes been made between 'primary' and 'secondary' alexithymia. Primary alexithymia has (by definition) a distinct neurological basis and a physical cause, such as genetic abnormality, disrupted biological development or brain injury. Secondary alexithymia results from psychological influences such as sociocultural conditioning, neurotic retroflection or defence against trauma. Secondary alexithymia is presumed to be more transient than primary alexithymia and hence more likely to respond to therapy.

However classification is rarely straightforward. If alexithymia results suddenly from a head injury, the cause is probably neurological; if it correlates with a history of abuse or neglect it might well be psychological. But there is no established functional distinction between neurological and psychological strains of alexithymia, and hence no acid test.

There are further complications for prognosis and treatment. The brain is continually changing both psychologically and neurologically. A developmental or biological failure may trigger a defensive psychology, which in turn causes the physical brain to develop abnormal 'wiring'. So while psychodynamic therapy may be the obvious choice in working to change secondary alexithymic defenses to more healthy ones, it may not be able to correct the years of built-up neural anomalies and brain tissue development.

The key question for each individual is whether the neural structures and pathways linking different aspects of emotion have been destroyed or are intact and unused. Several high profile research teams are investigating the neurobiology of alexithymia, so watch this space.

(There is a more pedantic philosophical objection to the psychological-neurological dichotomy. Most experts believe all mental or psychological phenomena correspond in some intimate way to physical or neurological properties, events or processes. Hence it is trivially true that nothing can be psychological without also being neurological—unless you believe in non-material spirits or souls. Either way, this is matter of metaphysical doctrine.)


What is the neural basis of alexithymia?

Investigations so far suggest two models of neural dysfunction.

The limbic-neocortical model proposes a disconnection between the limbic system and the neocortex. The limbic system triggers and co-ordinates the physiological reactions to emotive stimuli, and the neocortex interprets what is happening and how it relates to personal goals. If the neocortex cannot access detailed information about the reactions or their association with the stimulus, then it cannot classify or interpret the emotion.

The interhemispheric model implicates faulty communication between the two cerebral hemispheres. The right hemisphere specialises in the sensing and contextual interpretation of internal feedback from bodily emotions. The left hemisphere specialises in categorisation, language and logic. The hypothesis is that the left hemisphere, which does the talking, is ignorant of the intuitive information in the right hemisphere. So although the person may behave emotionally at a subconscious level, he or she will sincerely deny it or confabulate an excuse. This phenomenon has been observed in split-brain patients, whose cerebral hemispheres have been disconnected.

It would be rash to make claims of exclusivity about either of these models. They may be responsible for different subtypes of alexithymia. Moreover, neither model precludes the possibility of developmental or psychodynamic causes.


What are the causes?

Different cases of alexithymia are likely to have different causes. Possibilities include heritable traits, genetic abnormalities, disrupted neural development, brain injury, mental trauma, psychological defence against stress or disease, and (arguably) cultural or parental conditioning.


How is it treated? Is there a cure?

The chief architects of alexithymia theory - Sifneos, Nemiah and Freyberger - argue that insight-oriented therapies are counterproductive. These methods provoke distress in alexithymic patients by focusing attention on their inability to understand their own emotions. In such cases it is preferable to concentrate on coping strategies.

Some psychologists believe that alexithymia can respond to psychotherapeutic interventions or talking therapies - slowly. For example, Krystal advocates an edifying approach, whereby the clinician explains how the patient somaticises his emotions and that such effects are temporary and to be experientially valued. The patient is then encouraged to identify and label the feelings appropriately. This is a very slow and potentially frustrating process. It should be left to the experts and should not be attempted by anyone with a naïve or common-sense theory of emotions. In common with most psychiatric therapies, it is not guaranteed to produce positive results.

The distinction between primary and secondary alexithymia is particularly relevant. Insight-oriented therapies are unlikely to work in primary alexithymia if the pathways linking key emotional areas of the brain have been destroyed; the edifying therapy may have some (limited) success. Conversely, secondary alexithymia is more likely to respond to psychodynamic therapies because it is believed to have a psychological cause.

There are no direct medications for this disorder. However, alexithymia is known to correlate with low mood, and some patients may benefit from antidepressants. This in turn may make it easier and more productive to focus on feelings and the interpretation of inner experiences.

Perhaps the greatest obstacle to treatment is getting the problem recognised. Many psychiatrists are are sceptical and some are downright dismissive, partly due to the theoretical confusions. Alexithymia doesn't (yet) constitute a formal diagnosis and the underlying deficit in emotional awareness is not officially recognised as a psychiatric disorder. In practice, most therapists are reluctant to acknowledge alexithymia and fail to appreciate why some clients cannot get in touch with their inner feelings. Sadly, until the syndrome is more widely publicised, professional help may not be available.


Are there any self-help techniques?

The following is a provisional list of self help guidelines (proposed by Triton).

  • Recognise Alex. Don't ignore it.
  • Don't try to correct failures by punishment or contempt.
  • Negotiate a 'co-supportive' relationship with a 'non-alex' person (e.g. therapist, friend, partner).
  • Cultivate a keener sense of other people's emotional needs judging by their verbal and physical cues.
  • Learn the BIGGEST repertoire of "appropriate" feeling responses you can, based on cues from others, and use them, even if they feel automated or phoney. This will get you through to your old age with the least amount of damage to yourself from mistakes.
  • Take time and patience to learn how to recognize and name your own emotional/feeling states.
  • Be wary of friends bearing common-sense advice: such suggestions are usually intended for people with a normal range of feelings and emotions, and may not be relevant to alexithymia.

Some sufferers find it helpful to maintain a predictable and stable routine, which helps to minimise anxiety.

Above all, it is extremely useful to have a co-supportive relationship with an understanding partner who can compensate for weaknesses. Here is some advice from a partner of an alexithymic (thanks to Triton once again):

"Integrate your functioning with someone who can anchor you in emotional areas when and where you need it, and who can pull you away from something when you are overdoing any projects, or can advise you on the feeling etiquette in various situations. You can do barter with this person by giving to them in ways that you are good at giving (e.g. offering them your neat reality sense, or helping them with intellectual tasks or maybe giving sports massage, or whatever other talents you have to barter), but the relationship would be based on a kind of contract in which you would come clean and tell this person that you cannot 'cut it' in the emotional arena, and they are not to expect you to do so. This person should be encouraged to seek a measure of emotional fulfilment outside of your relationship, with others, in order to be sated in their own affective needs. A girlfriend/boyfriend would be the image that comes to mind as the best choice because they will be present often, or a second choice choice might be a friend, therapist, colleague (or several such co-supportive relationships)."


I've heard it is related to psychosomatic disorders. How?

The concept of alexithymia was inspired by the analysis of psychosomatic patients who responded poorly to traditional psychotherapy due to a lack of insight into their emotions and feelings. It was proposed that alexithymia might be a causal factor in the development of psychosomatic disease.

However, it should be noted that the correlation with psychosomatic illness is statistical at best. The theorists who developed the concept were aware of cases of alexithymia that did not coincide with psychosomatic illness.

The alexithymia hypothesis of psychosomatic illness goes something like this. A typical alexithymic responds to emotive stimuli in the normal physiological ways: her stomach churns, her skin crawls, and her muscles tense. Failing to identify the corresponding feelings as signals of emotional significance, she interprets them as symptoms of physical illness and feels unwell rather than emotional. Accordingly she does not take steps to deal appropriately with the cause of the emotion and her physiological reactions continue unabated, possibly causing genuine physical disease. How does this happen?

Think about when you get excited about something (the "Yippee!" feeling): your pulse rises, and you become increasingly animated as your body prepares for action. Or when it suddenly dawns on you that you've made a terrible mistake (the "Oh … shi …" feeling): adrenaline (epinephrine) pumps into your blood, your stomach clenches and you feel jittery, nauseous and weak. Now imagine you have no idea why your body is doing these things and you can do nothing about it. Real changes take place in your body: blood is directed away from your stomach to your muscles; consequently your digestion slows and you feel uptight. After a while you will feel serious stomach cramps and fatigue. If it's sustained for a long period, it may result in distressing psychosomatic or somatoform illnesses, such as gastroenteritis, irritable bowel syndrome, or chronic muscular pain.

Note that this is a hypothesis about a possible cause of psychosomatic illness, not about a feature of alexithymia. Hence psychosomatic illnesses are not included in the diagnostic criteria for alexithymia.


How does alexithymia affect decision-making?

There is mounting evidence that our emotions are crucial to beneficial decision-making, and that alexithymics seem to be deficient in this central component of emotional intelligence. There are two main reasons for this.

First, emotions are appetitive motivations: they play a crucial role in determining our goals and protecting our interests. If we cannot interpret their messages, we fail to incorporate this information into our decisions. Hence alexithymics tend to make decisions for practical reasons rather than sentimental or hedonistic reasons, and lead joyless and unrewarding lives.

Second, the affect system uses a different form of information processing than the intellectual system. It is more holistic and distributed and specialises in quick and dirty reactions to thoughts about our personal welfare or interests. By contrast, the intellect progresses from one logical step to another, but it takes a lot of time and processing power and is liable to overlook important information. Both methods have strengths and weaknesses. Alexithymics are frequently highly intelligent with utilitarian moral principles, but they tend to be non-intuitive and easily overwhelmed by practical tasks.

Alexithymics may appear very indecisive when the question relates to personal preferences. They will tend to seek other people's opinions and decide on that basis.


What wrong with the alexithymic imagination?

The imagination normally utilises both the conceptual and affective systems by uniting them in a quasi-perceptual mental image. Alexithymics seem to lack the affective contribution to these mental images. Their imagined scenarios are generally devoid of emotional content. The same holds true for images reconstructed from memory. Hence they have an impaired fantasy life and inferior emotional memory.

If an alexithymic imagines a situation that would be typically exciting or motivating (e.g. a foreign holiday) the prospect seems bland. The factual information is all there, and the visualisation may be accurate, but the images have no personal or motivational significance. Similarly, some alexithymics report problems with emotional memories, especially childhood memories. Normal people have a kind of emotional index of memories (the so-called 'flashbulb' memory) which takes a snapshot of perceptual information at times of high emotion. It appears that alexithymics either have difficulties with labelling the memories as emotionally significant or with recalling them via emotional cues.


Are all men partially alexithymic?

The stereotypical male is renowned for making obtuse remarks in sensitive contexts, for being unable to talk about his feelings and for misunderstanding emotional signals from partners. (For prime examples, see John Gray's Men are from Mars & Women are from Venus books). Does that mean that the typical man is alexithymic? No. It's a myth founded on a misunderstanding.

The stereotypical male may not say anything about his emotions and may have difficulty trying to verbalise his feelings. But he is also fiercely passionate—about women, cars, football, career, house and children. He has not been educated or encouraged to express his feelings verbally, but he understands what they imply and acts accordingly.

It is arguable that men (in general) are less able to understand the signs and implications of social emotions than women (in general). Women are reputedly more intuitive and sensitive to the emotions of others. This may be partly due to learned cultural gender roles and partly to sex differences in neural organisation. Men may be poor at social intuition while being adept at heeding their own feelings and hunches. The trait does not necessarily imply the type of deficit associated with alexithymia, and hence is sub-diagnostic for that disorder.

In summary, though it appears more males than females are alexithymic, alexithymia is by no means a 'typical' male trait.


How does alexithymia affect parenting?

It is difficult to say because there is insufficient data. There have been as yet no empirical studies of alexithymia in the parenting context.

However, there is more information available about parents with Asperger's syndrome or High Functioning Autism (HFA), who have an alexithymic emotional profile. (See, for example, Anna's Pregnancy, Parenting and Autism resource, in particular the Alien Parenting page.) Reports suggest that people with Asperger's can be very successful parents, provided they have adequate support. It is important not to overload the parent with too many (possibly conflicting) practical demands and to allow for periods of rest.

You can also read about the experiences of parents and grandparents of children with Asperger's. There are some excellent recommendations for encouraging emotional awareness in Tony Attwood's Asperger's Syndrome: A guide for Parents and Professionals.


Where can I talk about alexithymia?

http://groups.msn.com/Alexithymiachatsite


Where can I read more about alexithymia?

A good article summarising the concepts, research and measurement of alexithymia can be found in most academic libraries:

Taylor, G. J., & Bagby, R. M. (2000) An overview of the alexithymia construct, in ed. R. Bar-On & J. D. A. Parker, The Handbook of Emotional Intelligence, San Francisco: Jossey-Bass Inc., Ch.3, pp.41-67.

The most comprehensive resource is a book by the same authors:

Taylor, G. J., Bagby, R. M., & Parker, J. D. A. (1997) Disorders of Affect Regulation: Alexithymia in medical and psychiatric illness, Cambridge: Cambridge University Press.

The best description of the original psychiatric syndrome can be found only in specialised medical libraries:

Nemiah, J. C., Freyberger, H., & Sifneos, P. E. (1976) Alexithymia: A view of the psychosomatic process, in ed. O. W. Hill, Modern Trends in Psychosomatic Medicine, London: Butterworths, pp.430-439.

You may find this reading list helpful.