Alexithymia, derived from the Greek roots meaning “no words for feelings,” refers to a pattern of difficulties in identifying, describing, and cognitively processing emotions. Historically, the term alexithymia was introduced by Sifneos (1970) within the context of psychosomatic and somatoform disorders, based on his collaborative clinical work with Nemiah. At that time, it was conceptualized as a dichotomous clinical variable. However, the phenomenon itself had been observed long before it was formally named. Various psychiatrists had described patients who showed marked difficulty in identifying and expressing emotions.
In the mid-twentieth century, psychosomatic disorders were largely interpreted through psychoanalytic frameworks, particularly Freudian models that attributed physical symptoms to unresolved unconscious conflicts. Yet the limited and inconsistent empirical support for these explanations, along with mixed evidence regarding the effectiveness of psychoanalytic treatments in psychosomatic populations, led to increasing criticism (1). These methodological and clinical concerns prompted researchers to seek alternative explanations and to examine individual differences that might account for treatment resistance and variability in outcomes.
One of the earliest clinical descriptions resembling what is now termed alexithymia was provided by Jürgen Ruesch in 1948 (2). In his attempt to understand therapeutic difficulties in psychosomatic patients, Ruesch introduced the concept of the “infantile personality.” He described individuals who struggled to translate emotional tension into symbolic expression and instead manifested it through bodily symptoms.
Ruesch emphasized socio-developmental factors in the acquisition of emotional language. According to his view, children raised in supportive psychosocial environments gradually learn to regulate internal tension through symbolic communication within interpersonal relationships. When this developmental process is disrupted, emotional arousal may remain at the somatic level, expressed through physical complaints rather than verbal or symbolic forms.
The absence of symbolic mediation, which Ruesch considered fundamental to social interaction, was also associated with impaired relational functioning. In the therapy room, these patients were characterized by a noticeable lack of affective expression and a concrete style of reporting experiences. Emotional content was often externalized or projected onto situational details rather than articulated directly.
Ruesch interpreted this pattern as a defensive mechanism that protected the individual from internal confusion. For therapeutic progress to occur, he argued, patients first needed to become aware of this defensive style and gradually develop the capacity for symbolic emotional expression before deeper exploration of past experiences could be possible.
Clinical reports have repeatedly documented the therapeutic difficulties encountered with patients who display alexithymic features. An illustrative example is provided by Lesser (1981), who described a patient suffering from chronic headaches that had significantly impaired his life goals (3).
When asked how antidepressant medication had affected him, the patient was inclined to describe changes in his well-being in terms of the presence or absence of physical symptoms (p.533):
In response to the therapist’s efforts to redirect the discussion toward emotional experience, the patient expressed frustration:
Throughout treatment, the patient’s speech was characterized by detailed accounts of work routines and external events, with minimal reference to internal states. The therapeutic process appeared stalled, not due to resistance in a conventional sense, but due to limited access to symbolic emotional articulation.
Such clinical observations help explain why certain psychoanalytic approaches encountered obstacles with similar patients. Early theorists, including Karen Horney, noted that individuals who displayed pronounced deficiencies in emotional awareness and imaginative life often showed limited responsiveness to techniques that relied on affective elaboration and dream analysis (1).
In this context, the challenge was not the absence of suffering, but the absence of a symbolic pathway through which suffering could be processed.
Similar clinical reports describing psychosomatic patients’ difficulties in expressing their feelings had appeared decades before Sifneos and Nemiah. In that sense, introducing the term alexithymia was not a discovery of an entirely new phenomenon. However, their contribution was significant. They provided a systematic and coherent conceptualization of a frequently observed clinical problem by reviewing dispersed theoretical and clinical observations and reexamining previously recorded interviews with psychosomatic patients.
Their description of alexithymia included four main features. To read them in more detail, you can expand the items below.
1. Difficulty identifying feelings ▾
This refers to a reduced ability to distinguish between different emotional states and to differentiate emotions from the physiological arousal associated with them.
To clarify, emotional stimuli typically produce bodily changes, such as alterations in heart rate, breathing, facial expression, or muscle tension. These bodily signals are then cognitively interpreted within a specific context, allowing the individual to label the experience as fear, anger, sadness, or joy. In the model proposed by Sifneos and Nemiah, alexithymia was characterized by a disruption in this interpretive stage. Emotional arousal is experienced at the physical level, but the individual does not move to the cognitive stage in which the emotion is consciously identified and differentiated.
Importantly, this does not imply an absence of emotion. Rather, the emotional experience remains at the somatic level without being symbolically processed, which was considered a contributing factor to the prominence of physical complaints in these patients.
2. Difficulty in expressing and describing feelings ▾
As the literal meaning of alexithymia suggests (“no words for feelings”), individuals experience marked difficulty in verbally expressing their emotional states. Emotional language tends to be limited, vague, or replaced by references to physical sensations or external events.
The earlier clinical example illustrates this clearly: “I don't know what you expect me to say when you ask how I feel.”
The difficulty lies not only in labeling emotions internally, but also in articulating them in a way that allows interpersonal understanding.
3. Diminished capacity for fantasy and imaginative thinking ▾
Another characteristic described by Sifneos and Nemiah concerns a reduced tendency toward fantasy and imaginative activity. Individuals high in alexithymia are less inclined to form mental images of events, people, or situations that are not immediately present. Daydreaming and symbolic elaboration are often limited.
This dimension is reflected in assessment tools such as the Bermond–Vorst Alexithymia Questionnaire (BVAQ) (4). For example, items measuring the fantasizing factor include: “Before I fall asleep, I imagine all kinds of events, encounters and conversations” (reverse coded), and “I think that fantasizing about imaginary things or events is a waste of time.”
Such items capture the reduced engagement in imaginative processes that typically support emotional symbolization.
4. Externally oriented thinking style ▾
This feature refers to a cognitive style in which attention is primarily directed toward external events rather than inner emotional experiences. Because emotional arousal does not readily generate subjective interpretations, associations, or fantasies, the individual tends to focus on concrete details of the environment (5).
This pattern was evident in the earlier clinical example. The therapist described the patient’s speech as being confined to technical details of his work and almost camera-like reports of daily interactions. Conversations remained factual and descriptive, lacking emotional elaboration. As a result, therapy reached a deadlock.
The externally oriented thinking (EOT) factor is also reflected in assessment instruments such as the Toronto Alexithymia Scale (TAS-20) (6). Example items include: “I would rather talk to people about their daily routines than their feelings.” “Seeking hidden meanings in movies or plays spoils their enjoyment.”
By gathering previously dispersed clinical observations under a distinct term and providing a coherent framework, Sifneos and Nemiah created a common ground for systematic research and theoretical debate. This conceptual clarification encouraged further empirical work and led to a more nuanced understanding of alexithymia.
Today, the way alexithymia is conceptualized has substantially evolved. Unlike its initial formulation as a categorical clinical variable, meaning that a person was either alexithymic or not, it is now widely regarded as a dimensional personality trait. In this view, individuals vary in degree, scoring higher or lower on alexithymia rather than fitting into a strict yes-or-no category. As a personality trait, it is considered relatively stable over time (7).
Importantly, alexithymia is no longer treated as a psychopathological symptom in itself. However, this does not mean it is unrelated to mental health. Similar to other personality traits, higher levels of alexithymia are associated with increased vulnerability to certain psychological difficulties and may worsen their course or prognosis. Contemporary research has significantly expanded the range of conditions linked to alexithymia beyond psychosomatic disorders, where the concept originally emerged. Accumulating evidence indicates elevated levels of alexithymia among individuals with anxiety disorders, depressive disorders, eating disorders, substance-related disorders, and post-traumatic stress disorder.
Moreover, because theoretical models of alexithymia emphasize a deficit in the cognitive processing of emotional arousal, a substantial body of recent research has examined its neurocognitive correlates. These studies suggest that higher levels of alexithymia co-occur with several neurological conditions, including traumatic brain injury, stroke, and epilepsy, as well as certain neurodevelopmental disorders such as autism spectrum disorder. Recent findings indicate that alexithymia is particularly prevalent among individuals with autism spectrum disorder, with reported rates ranging between 40% and 65% (8)(9).
Recent research has also examined whether alexithymia contributes to the social difficulties observed in certain clinical populations, particularly autism spectrum disorder. Some findings suggest that the degree of alexithymia, rather than the severity of autism itself, better predicts impairments in empathic abilities (10).
The proposed link between alexithymia and empathy is grounded in the idea that awareness of one’s own affective state forms the basis of empathic understanding. In social interaction, an individual first experiences a psychophysiological reaction in response to another person’s situation. This reaction is then cognitively appraised and labeled as a feeling. Empathy involves a further step: attributing that consciously recognized feeling to the other person. For example, “I feel sad because I saw her being scolded by her boss.”
If individuals have difficulty identifying and labeling their own emotions, as is characteristic of alexithymia, they may lack the conscious emotional representation necessary to attribute similar states to others (11).
Neuroimaging studies provide additional support for this account. Functional MRI findings indicate reduced activation in the anterior insula among individuals with high levels of alexithymia, a region closely associated with interoception, that is, the perception of internal bodily states. The anterior insula is thought to play a key role in transforming bodily signals into consciously reportable feeling states. Reduced activation in this region is therefore consistent with both diminished emotional awareness and lower empathic responsiveness (11).
REFERENCES
(1) López-Muñoz, F., & Pérez-Fernández, F. (2020). A History of the Alexithymia Concept and Its Explanatory Models: An Epistemological Perspective. Frontiers in Psychiatry, 10. https://doi.org/10.3389/fpsyt.2019.01026
(2) Ruesch, J. (1948). The Infantile Personality. Psychosomatic Medicine, 10(3), 134-144. Retrieved from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.469.1641&rep=rep1&type=pdf
(3) Lesser, I. M. (1981). A Review of the Alexithymia Concept. Psychosomatic Medicine, 43(6), 531-543. https://doi.org/10.1097/00006842-198112000-00009
(4) Vorst, H. C., & Bermond, B. (2001). Validity and reliability of the Bermond–Vorst Alexithymia Questionnaire. Personality and Individual Differences, 30(3), 413-434. https://doi.org/10.1016/S0191-8869(00)00033-7
(5) Šago, D., & Babić, G. (2019). Roots of Alexithymia. Archives of Psychiatry Research, 55(1), 71-84. https://doi.org/10.20471/may.2019.55.01.06
(6) Bagby, R. M., Parker, J. D., & Taylor, G. J. (1994). Twenty-item Toronto Alexithymia Scale. PsycTESTS Dataset. https://doi.org/10.1037/t01318-000
(7) Härtwig, E. A. (2019). Towards a comprehensive understanding of alexithymia. Retrieved from https://refubium.fu-berlin.de/bitstream/handle/fub188/27999/Dissertation_Alkan_Haertwig.pdf?sequence=3&isAllowed=y
(8) Oakley, B. F., Jones, E. J., Crawley, D., Charman, T., Buitelaar, J., Tillmann, J., . . . Loth, E. (2020). Alexithymia in autism: Cross-sectional and longitudinal associations with social-communication difficulties, anxiety and depression symptoms. Psychological Medicine, 1-13. https://doi.org/10.1017/S0033291720003244
(9) Ricciardi, L., Demartini, B., Fotopoulou, A., & Edwards, M. J. (2015). Alexithymia in Neurological Disease: A Review. The Journal of Neuropsychiatry and Clinical Neurosciences, 27(3), 179-187. https://doi.org/10.1176/appi.neuropsych.14070169
(10) Härtwig, E. A., Aust, S., Heekeren, H. R., & Heuser, I. (2020). No Words for Feelings? Not Only for My Own: Diminished Emotional Empathic Ability in Alexithymia. Frontiers in Behavioral Neuroscience, 14. https://doi.org/10.3389/fnbeh.2020.00112
(11) Bird, G., & Viding, E. (2014). The self to other model of empathy: Providing a new framework for understanding empathy impairments in psychopathy, autism, and alexithymia. Neuroscience & Biobehavioral Reviews, 47, 520-532. https://doi.org/10.1016/j.neubiorev.2014.09.021
Comments
Post a Comment