I Don’t Know What to Say When You Ask How I Feel - Alexithymia

Alexithymia is a personality construct whose Latin compounds literally mean “no words for feelings”. 

In this text you're going to read about: 

• The emergence of the alexithymia concept,
• Description of alexithymia by Sifneos and Nemiah,
• Explanatory examples for the core features,
• Recent approaches,
• Empathic abilities in alexithymia,
• Neural substrates

Historically, alexithymia was first put forward in the context of somatoform disorders by Sifneos (1970) as a dichotomous clinical variable based on a conjoint work with Nemiah. In fact, clinical observations related to alexithymia were already reported by many psychiatrists, way before Sifneos brought about the term. At that time, psychosomatic disorders were explained through Freudian theories which highlight the unconscious conflicts as a reason for physical symptoms. However, difficulties to reach empirical evidence which has already caused to get theories of Freud frequent criticism throughout his life continued to be the main reason for criticism to psychoanalytic explanations of psychosomatic disorders as well. The criticisms have become even stronger as a result of inconsistent evidence for the benefits of psychoanalytic treatments with psychosomatic patients(1). These inconsistent findings made new studies obligatory to find individual and technical factors affecting treatment outcomes.

Infantile Personality by Jürgen Ruesch

One of the earliest and significant clinical observations similar to features of now called alexithymia was reported in 1948 by Jürgen Ruesch in his study aiming to analyze reasons of difficulties faced with psychosomatic patients in treatment(2). In his paper, he described a construct that he called as immature personality which includes infantile self-expressions that cause emotions that are not adaptively expressed to be displayed as physical symptoms. He pointed out socio-developmental shortcomings as an obstacle to learning symbolic expressions of emotions. To him, a child from a healthy psychosocial environment learns to resolve tension inside of him through self-expression that takes place in interpersonal relations. However, if the child could not get the chance to learn it, the tension continues to be demonstrated physically as organ expressions rather than symbolically as verbal language. Because of the absence of symbolic expression, which is the very basis of social interactions, he pointed out that infantile personality is also characterized by having poor and problematic social relationships. To Ruesch, because infantile personalities cannot transfer their internal tension into verbal, gestural, or symbolical language, it was a huge stumbling block for techniques of psychoanalytic therapies. He stated that patients with infantile personalities in the therapy room stand out with a distinct lack of verbal and gestural affect while talking about their memories and relationship with others. They were describing their emotions by projecting them onto outside objects. Note that Ruesch in his paper considered this external projection of emotions as a sort of defense mechanism which helps the person to run away from his internal confusions. He indicated that initially, it is necessary to make the client aware of this defensive system and to teach him to express emotions symbolically in order to proceed to the stage in which the patient talks about his past and traumas.

Alexithymia in Therapy Room - What are the obstacles?

To infer, I would like to share a dialogue of a patient in psychotherapy who had been struggling with serious headaches for years that prevented him to achieve his dream to be a pilot(3). When the therapist wanted to know that how did antidepressant pills affect him, the patient’s answer was unclear, indirect, and lack of insight. He inclined to describe changes in his wellbeing in terms of a presence or absence of physical symptoms: (p.533)

I guess I was depressed. Those pills stopped me from crying, but I don't feel differently, I still have headaches. 

Although the patient was deliberately directed to the talk about his feelings towards the inferences caused by headaches, the patient continued with the same attitude and even appeared to be frustrated by the question:

I told you, I have headaches. I don't know what you expect me to say when you ask how I feel.

In the report, the therapist pictured the speech of the patient throughout the therapy as being trapped into details of his work and monotonous reporting of dialogues with his environment.

Based on the descriptions given so far, I assume that it's not hard to see how this kind of emotionally absent speech lacks all the substance that psychoanalytic therapy works on. This was the reason why Karen Horney, one of the important pioneer theorists of psychoanalysis, in the early 1950s highlighted the fact that these types of patients were immune to psychoanalytical treatment. She characterized them as displaying significant deficiency in emotional awareness and expression and having no interest to talk about dreams and fantasies(1).

Description of Alexithymia by Sifneos and Nemiah

So, similar reports regarding difficulties of psychosomatic patients in expressing their feelings followed each other simultaneously and independently decades before Sifneos and Nemiah. Therefore, coming up with the term of alexithymia wasn’t a eureka moment of exploring something totally new.  Yet, it doesn’t make their contribution to the issue any less valuable. They were the ones who provided a neat conceptualization to a frequently cited problem in the treatment of psychosomatic diseases by systematically reviewing dispersed clinical and theoretical data and reexamining previously tape-recorded interviews of psychosomatic patients. Their description of alexithymia included four main features: 

1.Difficulty to identify feelings

It implies a deficiency to distinguish between different kinds of feelings and a deficiency to distinguish between feelings and physiological symptoms aroused by emotions. 

To illustrate better, a person experiences emotional arousal on the physical plane(e.g. changes in heart rate, respiration, or smiling, crying, etc.) in response to the emotional stimuli and there is a subsequent stage of mental inference that is made from this arousal and other external variables(e.g. the context in which the physical changes took place). This inference makes individuals able to conclude whether they are scared, angry, or happy. So, to the model of Sifneos and Nemiah, alexithymia was characterized by the absence of that inference stage. Therefore, it doesn’t mean they don't have emotions. They have but, they just left it on the physical level and don't proceed to the cognitive stage where the emotion is consciously processed. That was considered as the reason why they suffer from physical complaints.

2.Difficulty to express and describe feelings

Remember the literal meaning of the alexithymia – no words for feelings

e.g. “…I don't know what you expect me to say when you ask how I feel.”

3.Diminished ability to fantasize and imaginative thinking

So, putatively, alexithymic people are indisposed to forming mental images of events, people, places, situations that are not present. They are disinclined to daydream. For example, In BVAQ (4), one of the widely used scales of alexithymia, two of the items for fantasizing factor are: "Before I fall asleep, I imagine all kinds of events, encounters and conversations."(reverse coded), "I think that fantasizing about imaginary things or events is a waste of time."

4.Externally oriented thinking style

It implies that alexithymic people orient their focus to details of external events. Since the external stimuli do not evoke any subjective feeling and concomitant inferences, ideas, fantasies on the individual’s mind, the person preoccupies with the concrete characteristics of his environment (5). Remember the therapist’s description of the sessions with the patient who was distressed from chronic headache as being stuck on technical details of his work and camera-recording type of reports of his relations which brought therapy to a deadlock. As an example, In TAS-20(6), another widely used scale of alexithymia, two of the items of EOT factor are: “I would rather talk to people about their daily routines than their feelings.”, “Seeking for hidden meanings in movies or plays kills their enjoyment.”

Current Conceptualization of Alexithymia

That Sifneos and Nemiah have collected the dispersedly shared findings under a distinctive term and given them a unifying framework yielded a shared groundwork to debate and thus encouraged researchers and clinicians to study on it. Consequently, it has provided a more accurate and profound understanding of the issue.

Indeed, today the way alexithymia is regarded has largely transformed. First of all, unlike its primary definition containing categorical approach (meaning one is either alexithymic or not), it is now considered as a dimensional personality trait (meaning one has a lower or higher score on it). Personality trait implies that it is consistent and stable over time(7). So, in contrast to earlier theories, alexithymia is no longer supposed as a psychopathological symptom but that doesn't mean alexithymia has nothing to do with psychological disorders. As with some other personality traits, a higher score of alexithymia increases the risk to develop a certain type of mental problems or worsens the prognosis of them. And the second change in the description of ALEX is that contemporary researches of alexithymia greatly wider the spectrum of pathologies associated with the alexithymia in addition to psychosomatic disorders which the construct primarily has born within. A large amount of evidence to date demonstrated that high-alexithymic trait has a high prevalence among patients with anxiety disorders, depressive disorders, eating disorders, addictive disorders, post-traumatic stress disorders. 

Moreover, because theories of ALEX emphasizes a deficiency in cognitive processing of emotional arousal, a large body of recently published studies have focused on neurocognitive correlates of alexithymia and found out that higher levels of ALEX co-occur with some neurological disorders including traumatic brain injuries, stroke, epilepsy also some neurodevelopmental disorders such as autism. Novel research reports a higher rate of ALEX among people with autism spectrum disorder with a prevalence of 40-65% (8)(9).

Empathic Abilities in Alexithymia and Neural Bases 

Some research then has focused on the notion of ALEX being an important determinant of the social difficulties seen in people with autism. Indeed, some evidence to suggest that the degree of alexithymia rather than the severity of the autism predicts impairment in empathic abilities has been shared(10). The hypothetical relationship between alexithymia and empathic abilities is also supported by brain imaging methods. The proposed relationship is based on the idea that awareness of one's affective state is the source of empathy.  

To be more specific; as a result of the interaction with someone else, the person develops a psychophysiological reaction (emotion), and then, as we mentioned earlier, he consciously appraisals of this reaction and names it(feeling). The empathy includes a further step including explicitly attributing the feeling that occurs in oneself to the other side: "I feel sad because I saw her scolded by her boss in front of everyone." Therefore, since alexithymic people have difficulties naming their own feelings, they won't have a conscious awareness of a feeling to attribute it to another (11). 

Studies with fMRI supported this theory with the evidence of lower level activation in anterior insula in highly alexithymic people associated with reduced empathy. The anterior insula is a region known to be involved in interoception which refers human's ability to perceive of own bodily signals and neurocognitive studies indicate that AI has a role in turning these perceived bodily signals into reportable feeling states. Considering the features of ALEX, reduced activation in Anterior Insula is quite meaningful and a concomitant reduced empathic ability is coherent with the theoretical explanation of empathy shared above (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. doi:10.3389/fpsyt.2019.01026

(2)Ruesch, J. (1948). The Infantile Personality. Psychosomatic Medicine, 10(3), 134-144. doi: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. doi: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. doi:10.1016/s0191-8869(00)00033-7

(5)Šago, D., & Babić, G. (2019). Roots of Alexithymia. Archives of Psychiatry Research, 55(1), 71-84. doi: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. doi: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. doi: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. doi: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. doi: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. doi:10.1016/j.neubiorev.2014.09.021

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