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Understanding Alexithymia: The Unspoken World of Emotions

Explore the unspoken world of emotions with our comprehensive guide to understanding Alexithymia. Learn about its origins, signs, assessment, and ongoing research.


Written by Sarah Talarico and reviewed by Shawn Horn PsyD, PS


A picture of a person holding their head and their face is blurred. This picture conveys that the person doesn't know what they are feeling. This picture is used to show or represent alexithymia.



What is Alexithymia? 


Alexithymia [ ey-lek-suh-thahy-mee-uh ] is a neuropsychological phenomenon that translates to “no words for emotions.” Essentially, people with alexithymia cannot identify, be aware of, or describe their emotions and have limited imaginative capacities. In addition, alexithymia is characterized by a stimulus-bound, externally oriented cognitive style, which means that a person with alexithymia is more focused on things outside of themselves rather than inwardly on their thoughts or feelings. Their challenge with their own emotions extends to others as well. They struggle with empathizing with others, perspective-taking, and understanding others' emotions and intentions.


Moreover, alexithymia may be associated with a deficit of interoceptive awareness. Typically, interoceptive awareness refers to knowing your body’s signals, such as your heartbeat, breathing, and feelings of hunger or thirst. In the context of alexithymia, interoceptive awareness involves recognizing bodily sensations associated with emotions. For example, noticing a faster heartbeat or upset stomach when feeling anxious, experiencing a tightening sensation in the chest when feeling sad, or shaking when experiencing anger.


It’s important to note that alexithymia doesn’t mean “unfeeling”; people with alexithymia still feel emotions but have difficulty understanding, recognizing, and expressing them. For example, a person with alexithymia may have emotional outbursts, intense feelings, or chronic dysphoria and yet not be able to link it to memories, understand where the emotion is coming from, or identify what they are feeling (Goerlich, 2018). 


Primary Alexithymia 


Primary alexithymia, alternatively known as trait or developmental alexithymia, is a more stable, consistent presentation of this condition. This version of alexithymia is considered more of a personality trait or characteristic and a fundamental aspect of an individual’s emotional processing and expression. Research suggests that genetics, biological factors, childhood trauma, and negative primary caregiver interactions may play a role in the development of primary alexithymia (Hogeveen & Grafman, 2021)


Secondary Alexithymia


Secondary alexithymia, also referred to as acquired or state alexithymia, occurs when alexithymic symptoms develop secondary to another condition or circumstance. This form of alexithymia is often temporary, unlike primary alexithymia. For example, environmental factors such as medical conditions, psychiatric disorders, or psychological trauma can trigger secondary alexithymia. These factors may include brain damage or dysfunction in neurological disorders, developmental arrests, significant psychological trauma during childhood or later in life, socioeconomic factors, or psychodynamic influences (Hogeveen & Grafman, 2021).


Understanding the Causes of Alexithymia


Despite ongoing research efforts, experts profess that they cannot make definitive claims on what causes alexithymia at this time. This lack of understanding of the exact causes of alexithymia is due to its complex nature, limited research, and the various factors that may contribute to its development. 


Current research suggests that alexithymia may be the result of a combination of genetics, environmental factors, developmental experiences, and traumatic brain injuries. 


Various social and psychological factors may also contribute to the development of alexithymia. Early childhood adversity, such as neglect or emotional trauma, has been shown to influence the development of alexithymia later in life. Moreover, cultural norms, biological sex, socioeconomic status, and certain mental health conditions, including anxiety and depression, may impact an individual's susceptibility to alexithymia.


Elevated levels of alexithymia have been observed in individuals who have neurovascular diseases and neurogenerative disorders such as multiple sclerosis, semantic and frontotemporal dementia, Alzheimer’s disease, corticobasal syndrome, Huntington’s disease, and Parkinson’s Disease (PD) (Hogeveen & Grafman, 2021).  


Overall, alexithymia is still widely understudied and has complex etiologies. Further research is needed to deepen our understanding of alexithymia and its underlying mechanisms.


Diagnosis


Alexithymia is not classified as a mental health disorder; therefore, it doesn’t have specific diagnostic criteria, and it cannot be diagnosed formally in the same way that conditions like depression, anxiety disorders, or schizophrenia are diagnosed.


While there is an ongoing debate on how to classify and measure alexithymia accurately, there are ways to recognize potential signs of alexithymia. Given that alexithymia manifests in varying forms of presentation and degree of severity, there is a range of assessment approaches. These methods include self-report scales, structured interviews, behavioral observations, and neuroimaging techniques. 


Self-report Scales 


Self-report scales are the most popular assessment methods used for identifying alexithymia. Two well-known scales are the Bermond-Vorst Alexithymia Questionnaire (BVAQ) and the 20-item Toronto Alexithymia Scale (TAS-20). 



The TAS-20 is a self-report scale that targets three factors of alexithymia: difficulty identifying feelings, difficulty describing feelings, and externally oriented thinking. This scale emphasizes the cognitive emotion-processing facet of alexithymia rather than the affective component. Cognitive emotion processing is perceiving what we feel and accurately labeling our feelings. 


  • Bermond-Vorst Alexithymia Questionnaire (BVAQ)


The BVAQ was developed to encompass both the cognitive emotion processing and the affective components of alexithymia. In addition to difficulty identifying feelings, describing feelings, and externally oriented thinking, the BVAQ includes difficulty fantasizing and emotionalizing. Fantasizing difficulties mean that an individual struggles with imaginative processes such as daydreaming and producing imaginary scenarios, and they may have reduced emotional richness in their fantasies. Individuals with emotionalizing difficulties usually struggle to associate emotional significance with emotional stimuli, experiences, or thoughts. 


This online alexithymia questionnaire, developed in 2005, overcomes some general shortcomings of other questionnaires, such as Bermond-Vorst or TAS-20.

Originally, the questionnaire was done by Jason Thompson, who intended to have a free alexithymia questionnaire available for the community. Click on the link to take the free online test.


Structured interviews


One example of a structured interview is the Toronto Structured Interview for Alexithymia (TSIA). The TSIA is similar to the TAS-20 and is a promising assessment for alexithymia. This interview has a four-factor structure in which clinicians ask individuals standardized questions about their emotional experiences and abilities. Structured interviews allow for a more in-depth exploration of alexithymic traits and may provide additional context to self-reported symptoms.


Behavioral observations


Behavioral observations directly observe an individual's behavior, expressions, and interactions to infer their emotional awareness and expression level. Observer-rated measures, such as the Observer Alexithymia Scale (OAS), provide an external perspective on alexithymia. Clinicians may ask anyone who knows the patient well, such as family members, friends, or therapists, to provide their observations and impressions of the individual’s behavior and emotional experiences. Moreover, the clinician may also make their observations during their interactions with the patient. Features that are looked for are lack of insight, emotional distance, somatization (psychosomatic tendencies), lack of humor, and rigidity (Lumley, Neely, & Burger, 2007).


Neuroimaging techniques


Neuroimaging, such as functional magnetic resonance imaging (fMRI), is used in research to investigate the brain activity of alexithymia. Regions of the brain involved in various aspects of emotional awareness, regulation, and interoception, such as the amygdala, insula, prefrontal cortex, anterior cingulate cortex, and somatosensory areas, have been implicated in alexithymia (Goerlich, 2018). Using neuroimaging, the brain’s activity to emotional stimuli can be observed. For example, it has been observed that the amygdala shows reduced activity and is consistently smaller in volume during emotional processing in individuals with higher levels of alexithymia (Goerlich, 2018).


Although neuroimaging provides new insights into the neural mechanisms underlying alexithymia, it’s important to note that neuroimaging research is still emerging, and further research is needed to fully understand this phenomenon's neural basis. 


Links to Mental Health Conditions


Alexithymia is present in multiple affective, developmental, and neurological disorders. Some of the disorders that increase the risk of developing alexithymia and are often associated with higher rates of alexithymia are ASD (autism spectrum disorder), PTSD (post-traumatic stress disorder), ADHD (attention-deficit/hyperactivity disorder), depression, and anxiety disorders such as OCD (obsessive-compulsive disorder) and GAD (generalized anxiety disorder). Alexithymia has also been associated with increased rates of addictive behaviors such as gambling, excessive mobile phone and internet use, and substance addiction (Hogeveen & Grafman, 2021)


Treatment


While no standardized treatments exist, various interventions aim to enhance emotional awareness and expression. Treatment approaches are controversial, as studies have shown different results and may have failed to observe such findings. Some studies have found that alexithymic patients respond less favorably or slowly to psychological treatments focusing on insight, emotions, or relationships  (Lumley, Neely, & Burger, 2007). Others have suggested that variations of psychodynamic therapy and treatments focused on the internal experience, such as mindfulness, will help alexithymic patients  (Lumley, Neely, & Burger, 2007). It has been proposed that psychotherapy may be beneficial for low-alexithymic individuals but may be less effective for high-alexithymic individuals (Samur et al., 2013). Cognitive-behavioral therapies and externally focused treatments, such as contingency management, may be better suited for alexithymia patients (Lumley, Neely, & Burger, 2007). Experts “hypothesize that coping skills training, including techniques such as relaxation, pleasant activity scheduling, distraction, activity-rest cycling,” communication skills, and biofeedback may be helpful for alexithymic patients (Lumley, Neely, & Burger, 2007).


Occupational therapy suggests treating alexithymia with interoception treatments. Here is a resource that explains more: Alexithymia & Interroception with Occupational Therapist Kelly Mahler.


Further research is imperative to develop evidence-based and effective treatments for alexithymia. Alexithymic individuals must seek professional help for tailored interventions and treatment for their needs. Since alexithymia can co-occur with other conditions, getting a comprehensive approach from a mental health professional is necessary. 


Conclusion


Alexithymia remains a complex, multifaceted, and intriguing phenomenon, with ongoing debates surrounding its definition, measurement, and underlying causes. Despite current research, a lack of consistency across studies makes definitive claims challenging. The interplay of biological, psychological, and environmental factors in the causality and influence of alexithymia adds another layer of intricacy and complexity to our understanding. Continued research is necessary for deepening our understanding of emotional processing and may lead to more effective interventions and treatments. 


Understanding and managing alexithymia can significantly improve quality of life, enhance interpersonal relationships, and reduce feelings of isolation and misunderstanding. If you or someone you know may be experiencing symptoms of alexithymia, consider reaching out to a healthcare provider for assessment and support.


 

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The information on the Inspired Living Blog is intended for educational and informational purposes only. It is not meant to replace professional psychological advice, diagnosis, or treatment. While the content on this blog is provided with the utmost care and accuracy regarding mental health and psychological topics, it is not a substitute for professional consultation with a qualified psychologist or healthcare provider.


Readers are advised that the understanding and interpretation of mental health issues are complex and highly individualized. Therefore, the insights and guidance provided on this blog should not be used to diagnose or treat any mental health condition independently. If you are struggling with mental health issues, it is crucial to seek the advice of a licensed professional who can provide you with personalized care and support.


 

References


Bagby, R. M., Taylor, G. J., Parker, J. D., & Dickens, S. E. (2006). The development of the Toronto Structured Interview for Alexithymia: item selection, factor structure, reliability and concurrent validity. Psychotherapy and Psychosomatics, 75(1), 25–39. https://doi.org/10.1159/000089224


Betka, S., Pfeifer, G., Garfinkel, S., Prins, H., Bond, R., Sequeira, H., ... Critchley, H. (2018). How Do Self-Assessment of Alexithymia and Sensitivity to Bodily Sensations Relate to Alcohol Consumption? Alcoholism: Clinical and Experimental Research, 42(1), 81–88. https://doi.org/10.1111/acer.13542


Elmas, H. G., Cesur, G., & Oral, E. T. (2016). Alexithymia and Pathological Gambling: The Mediating Role of Difficulties in Emotion Regulation. Turkish Journal of Psychiatry. Retrieved from http://www.turkpsikiyatri.com/default.aspx?modul=doi&doi=u13779


Gao, T., Li, J., Zhang, H., Gao, J., Kong, Y., Hu, Y., & Mei, S. (2018). The influence of alexithymia on mobile phone addiction: The role of depression, anxiety and stress. Journal of Affective Disorders, 225, 761–766. https://doi.org/10.1016/j.jad.2017.08.020


Goerlich, K. S. (2018). The Multifaceted Nature of Alexithymia - A Neuroscientific Perspective. Frontiers in Psychology, 9, 1614. https://doi.org/10.3389/fpsyg.2018.01614


Hogeveen, J., & Grafman, J. (2021). Alexithymia. In Handbook of clinical neurology (Vol. 183, pp. 47–62). https://doi.org/10.1016/B978-0-12-822290-4.00004-9


Lumley, M. A., Neely, L. C., & Burger, A. J. (2007). The assessment of alexithymia in medical settings: Implications for understanding and treating health problems. Journal of Personality Assessment, 89(3), 230–246. https://doi.org/10.1080/00223890701629698


Mahler, K. (2022, September 21). Alexithymia & Interoception Livestream and Q&A [Video]. YouTube. https://www.youtube.com/watch?v=8G2E8ymGNJU


Mul, Cl., Stagg, S. D., Herbelin, B., Serino, A., & Farne, A. (2018). The Feeling of Me Feeling for You: Interoception, Alexithymia and Empathy in Autism. Journal of Autism and Developmental Disorders, 48(8), 2953–2967. https://doi.org/10.1007/s10803-018-3564-3


Paul R. Stasiewicz, Clara M. Bradizza, Gregory D. Gudleski, Scott F. Coffey, Robert C. Schlauch, Sydney T. Bailey, Christopher W. Bole, Suzy Bird Gulliver. (2012). The relationship of alexithymia to emotional dysregulation within an alcohol dependent treatment sample. Addictive Behaviors, 37(4), 469–476. https://doi.org/10.1016/j.addbeh.2011.12.011


Samur, D., Tops, M., Schlinkert, C., Quirin, M., Cuijpers, P., & Koole, S. L. (2013). Four decades of research on alexithymia: Moving toward clinical applications. Frontiers in Psychology, 4, 861. https://doi.org/10.3389/fpsyg.2013.00861


Schimmenti, A., Passanisi, A., Caretti, V., La Marca, L., Granieri, A., Iacolino, C., ... Billieux, J. (2017). Traumatic experiences, alexithymia, and Internet addiction symptoms among late adolescents: A moderated mediation analysis. Addictive Behaviors, 64, 314–320. https://doi.org/10.1016/j.addbeh.2015.11.002


Swart, M., Kortekaas, R., & Aleman, A. (2009). Dealing with feelings: Characterization of trait alexithymia on emotion regulation strategies and cognitive-emotional processing. PloS One, 4(6), e5751. https://doi.org/10.1371/journal.pone.0005751


Tatar, A., Saltukoğlu, G., Alioğlu, S., Çimen, S., Güven, H., & Ay, Ç. E. (2017). Measuring Alexithymia via Trait Approach-I: A Alexithymia Scale Item Selection and Formation of Factor Structure. Noro Psikiyatri Arsivi, 54(3), 216–224. https://doi.org/10.5152/npa.2017.12769







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