The Alexithymia FAQ

Version 2.0, July 28, 2003 (originally posted Jan 16, 2003)

This Frequently Asked Questions (FAQ) resource is designed to give representative answers to common questions about the psychological construct of alexithymia.

Please contact hal @ alexithymia.info with any suggestions or comments. You can also pose queries on the Alexithymia chatsite.

THE ALEXITHYMIA FAQ

What is alexithymia?

What is it not?

Why haven't I heard of alexithymia before?

How do I tell if I'm alexithymic?

Where did the term originate?

What are the key features of the alexithymia syndrome?

How is it formally assessed?

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

What is the difference between primary and secondary alexithymia?

Is it psychological or neurological?

Which neurological structures are implicated in alexithymia?

What are the causes?

How is it treated? Is there a cure?

Are there any self-help techniques?

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

How does alexithymia affect decision-making?

What wrong with the alexithymic imagination?

Are all men partially alexithymic?

How does alexithymia affect parenting?

Where can I talk about it?

Where can I read more about it?

What is alexithymia?

In brief, 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, and the construct of alexithymia refers to some of the chief manifestations of this deficit in emotional functioning. (You can read some more precise definitions here.)

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", but that is not what the term means. Its meaning is determined by its definition and is not constructed from the literal senses of its etymological roots. The term means the syndrome described in the literature and not simply an absence of emotion words.

Two conceptions of alexithymia

There are two closely related conceptions of alexithymia in the academic literature—psychiatric (in medical literature) and psychometric (in psychological literature), though the distinction is rarely acknowledged.

The psychiatric concept emerged in the context of psychosomatic medicine. Alexithymia in this sense refers to a set of characteristics, similar to la pensée opératoire, observed in a subset of psychosomatic patients. The classification is applied to people who exhibit the key symptoms of a deficiency in emotional cognition, as determined by a standard examination protocol, such as the Beth Israel Questionnaire. Alexithymia may be used to describe the behavioural profile of patients with a number of different syndromes, but it does not constitute a clinical disorder in its own right. It is a general clinical descriptor, like akinesia (lack of movement), aboulia (lack of will) or apnoea (breathing difficulties).

Alexithymia has a non-medical range of application in psychometric psychology. Here it is principally conceived as a dimensional personality trait. It implies a continuous range of abilities and although people who have an alexithymia rating above a certain arbitrary value can be classified as alexithymic, the term is not necessarily indicative of a clinically significant impairment. The difference in definition is subtle but important.

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 non-clinical 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.

What is it not?

There are many popular misconceptions about alexithymia. Web searches on the term return links to a range of conflicting definitions and descriptions. Erroneous definitions confuse alexithymia with other conditions or disorders involving a lack of emotion or of emotional expression.

For the record, alexithymia should not be confused with:

Sociopathy (a lack of concern for others)
Stoicism (deliberate resistance of emotional impulses)
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?

Alexithymia has not been well publicized. 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:

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 the psychiatrists Peter E. Sifneos and John C. Nemiah, working at the Beth Israel Hospital at Harvard, 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 Sifneos coined the term alexithymia to refer to this bundle of characteristics. He introduced it in two publications; in an article entitled "The Prevalence of 'Alexithymic' Characteristics in Psychosomatic Patients" published in the book Topics of Psychosomatic Research in 1972 and in the journal Psychotherapy and Psychosomatics in 1973; and (briefly) in his 1972 book Short-Term Psychotherapy and Emotional Crisis.

What are the key features of the alexithymia syndrome?

Please note this is not a checklist. There is still some debate about which characteristics are central to the construct.

Is it true that alexithymics have no emotions?

Not exactly. For one thing, this is not a simple question. There are several common definitions of "emotion", and each gives a different answer.

Many neuroscientists define emotions as specifc types of physiological responses. Alexithymics do exhibit this kind of reaction, though they are typically unaware of doing so. (Some studies have shown that alexithymics react more than normal subjects; others have found the opposite.) According to the physiological definition of emotion, alexithymic people have emotions like anyone else, but fail to recognize them or understand their emotional significance.

Some cognitive psychologists and philosophers maintain that emotions are special kinds of attitudes or thoughts, distinguished by an immediate concern for personal welfare. Alexithymic people are capable of having these thoughts, though they are not likely to dwell on them or prioritize them.

However, many people regard emotions as complex mental states which incorporate an awareness of a feeling, an automatic comprehension of its meaning and an automatic attitude towards the perceived cause. Some or all of these aspects of awareness are impaired in alexithymics. Accordingly, on this definition, alexithymics have few emotions. But that does not mean they have none.

Alexithymic people can occasionally experience full-blown emotions, if the physiological reaction is particularly strong and the cause is obvious. Strong emotions, such as rage, tend to take alexithymics by surprise, and they may not be able to limit their expression in behavior.

Some alexithymics are also prone to chronic anxiety and depression. The anxiety is partly due to a failure to correctly label emotions that energize the body for action, which tend to be experienced psychologically as undifferentiated anxiety. Depression takes a very bodily form in alexithymics. Negative thoughts activate the parasympathetic nervous system and cause neurotransmitter depletion in various parts of the brain, producing heavy feelings of sluggishness and slow reactions in body and mind. The result is a very somatic form of depression which the patients may have difficulty elaborating on or explaining.

How is alexithymia 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 more complex than a singular property, quality or characteristic. Instead, it refers a bundle of concurrent characteristics. In the psychiatric sense, alexithymia is a clinical syndrome, not in the sense of a disease or illness, but "a characteristic combination of opinions, emotions, behaviour, etc." (Oxford Concise Dictionary, 9th edn.).

Alexithymia is indicative of a dysfunction in the cognitive processing of emotion, and for convenience the term is often used to refer to this underlying psychological problem, though such usage deviates from the accepted technical meaning. It is controversial to describe the dysfunction as a disorder, because it has not yet been offically defined as such by the psychiatric profession and is not listed in the DSM-IV or the ICD-10. The term condition is quite vague, however, and is acceptable in most contexts.

Most of the recent research literature in psychology describes alexithymia as a personality trait. This means it is a persistent feature of a person's behaviour. In a more restricted technical sense, it refers to a qualitative dimension of individual variation as measured by a psychometric scale.

You may find alexithymia defined as a developmental, psychodynamic or neurological condition. Despite the strong evidence for developmental or psychodynamic causes and specific neurological abnormalities, each of these descriptions prejudges empirical research in a very partisan way. Similarly it is inappropriate to describe alexithymia as a thinking style, a neurotic defence or a neural anomaly, as these hypotheses have yet to be proven.

What is the difference between primary and secondary alexithymia?

The primary/secondary classification system was introduced early on by one of the original team of alexithymia researchers:

Nemiah, Freyberger & Sifneos (1976)

Finally, it is of interest that some patients with severe, life-threatening or debilitating bodily conditions may develop an alexithymic picture in the course of their illness. This is particularly the case with individuals in renal dialysis or intensive care units (Freyberger, in press) and has been termed by one of us (H.F.) 'secondary alexithymia'. Possibly related to a protective denial of the significance and seriousness of the illness, it either disappears when the somatic illness ameliorates or may become chronic in those whose disease remains incapacitating.

"Alexithymia: A View of the Psychosomatic Process", p.434.

For Freyberger, primary alexithymia is an enduring feature of a patient's profile, like a personality trait, that changes little over time or with changing circumstances. Secondary alexithymia, on the other hand, occurs in reaction to severe psychological trauma, whereby a patient suppresses painful emotions as a temporary defence against trauma; when the psychological stressor is removed, the alexithymia disappears.

In later years, Sifneos reconceptualized the primary/secondary distinction, basing it on the difference between neurological causes and psychological causes. In Sifneos's terms, 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 or training.

Due to the possible ambiguity of the primary/secondary distinction most contemporary authors prefer not to use it.

Is it psychological or neurological?

This question is often asked of psychiatric syndromes, usually with the aim of attributing responsibility or identifying suitable therapies. There is evidence that alexithymia can be either neurogenic (caused by biological abnormalities) or psychogenic (caused by upbringing or psychological trauma).

If alexithymia results suddenly from a head injury, the cause is probably neurological; if it correlates with a history of abuse or neglect it is probably psychological. But it is rare for the cause to be so readily identifiable. In fact, there is no recognized functional distinction between neurological and psychological strains of alexithymia, and hence no clinical test to ascertain the cause.

Moreover, 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 defences to more healthy ones, it may not be able to correct the years of built-up neural anomalies and brain tissue development. So psychological and neurological causes may be intimately intertwined and inseparable in analysis.

Nonetheless the question is still worth posing. If the neural structures and pathways linking different aspects of emotion processing have sustained damage by injury or atrophy, the alexithymia may be completely irreversible and the focus should be on learning new compensatory coping strategies. However, if the structures and pathways are still intact but underused (perhaps the neural activity is being inhibited by other processes), then there is a greater prospect of reducing the alexithymia by psychotherapeutic intervention. (Accordingly Sifneos—who works with neurological alexithymics—favours compensatory strategies; whereas Krystal—who works with post-traumatic alexithymics—promotes a form of therapy based on personal training and education in feelings and their psychological signficance.)

Which neurological structures are implicated in alexithymia?

Investigations so far suggest two models of neuropsychological 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 specializes in the sensing and contextual interpretation of internal feedback from bodily emotions. The left hemisphere specializes 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, as they may be responsible for different subtypes of alexithymia. It is possible that psychological cases of alexithymia may result in a reduction of neural signalling in these pathways without any physical damage to neural structures.

What are the causes?

Different cases of alexithymia are likely to have different causes. The main possibilities suggested so far include heritable traits, genetic abnormalities, disrupted neural development, brain injury, mental trauma, psychological defence against stress or disease, and cultural or parental conditioning.

How is it treated? Is there a cure?

The chief architects of alexithymia theory—Sifneos and Nemiah—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 identifying compensatory coping strategies.

Some psychologists believe alexithymia can respond to psychotherapeutic interventions or talking therapies—albeit slowly. For example, Krystal advocates an edifying approach, whereby the clinician explains how the patient somaticizes 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 to the prospects of therapeutic success. Insight-oriented therapies are unlikely to work if the pathways linking key emotional areas of the brain have been destroyed; it would be fruitless to attempt to train the patient to identify his or her feelings accurately if the brain structures responsible for emotional intuition are not in working order. Conversely, post-traumatic alexithymia is more likely to respond to training and education in feelings and emotions because the requisite neural structures are believed to be intact.

There are no direct medications for alexithymia. 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 recognized. Many psychiatrists are are skeptical and some are downright dismissive, partly due to the continuing confusions over definition. Alexithymia doesn't constitute a formal diagnosis and the underlying deficit in emotional awareness is not officially recognized 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 publicized, 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).

• Recognize 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 suitable for alexithymics.

Some alexithymics find it helpful to maintain a predictable and stable routine, which helps to minimize 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 states that in some psychosomatic patients the illness may be attributable to a chronic inability to regulate emotions adequately (as indicated by alexithymia). 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.

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 specializes 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 are easily overwhelmed by practical tasks.

Alexithymics may appear very indecisive when presented with questions relating to personal preferences. Unable to answer on the basis of gut feeling, they will tend to seek other people's opinions and decide on that basis.

What's wrong with the alexithymic imagination?

The imagination normally utilizes 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 verbalize 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. He may be deficient in emotional expression but he shows no impairments in awareness of feelings or in understanding what the feelings signify. Hence he is not alexithymic.

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. The typical man may be poor at social intuition while being adept at heeding his own feelings and hunches. The trait is a common trait, which is merely incidental to alexithymia, and hence is sub-diagnostic for that condition.

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?

There have been as yet no empirical studies of alexithymia in the parenting context, but a capacity for empathy and emotional communication is believed to play an important role in an infant's personality development.

There is more information available about parents with Asperger's syndrome or High Functioning Autism (HFA), who have an alexithymic emotional profile. 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.

You might find useful parenting tips on the alexithymia chatsite (see below).

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 specialized 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.