Alexithymia (1): A Closer Look at the Emotional Unknown

The term “alexithymia” was coined by psychotherapist Peter Sifneos (1973) to describe a relative constriction in emotional functioning, poverty of fantasy life and inability to find appropriate words to describe their emotions. For lack of a more suitable term, he called these characteristics ‘alexithymic’[1]. Since that time research investigating the alexithymia construct has considerably broadened:

Alexithymia is a multifaceted personality trait characterised by difficulties in emotion recognition and regulation (Swart et al. 2009), struggles in distinguishing between feelings and bodily sensations, challenges in communicating feelings; externally oriented thinking (EOT)[2] (Nowakowski, McFarlane, Cassin 2013; Bagby et al. 2020) and a reduced inclination to imagination (Rosenberg et al. 2020).

Those with alexithymia may struggle with social interactions, forming and maintaining relationships. It can be particularly problematic in professional settings where emotional intelligence and effective communication are critical for success. Individuals with alexithymia may struggle with understanding their coworkers' perspectives, interpreting workplace dynamics, or responding appropriately to feedback.

While there is no formal diagnosis for alexithymia (as it is a subclinical condition), there are assessment tools such as the Toronto Alexithymia Scale (TAS) or the Bermond-Vorst Alexithymia Questionnaire (BVAQ)[3] that can help identify its symptoms.

Numerous research studies have identified the common characteristics observed in alexithymia.

Emotional & cognitive issues

Individuals with alexithymia struggle to label what they're feeling, have poorer recognition of emotional expressions in faces (Grynberg et al. 2012; Cook et al. 2013) and lower recall of emotional material (Luminet et al. 2006). They also have an impairment in mentalising (theory of mind) associated with an inability to take the perspective of others (Moriguchi et al. 2006).

These characteristics are thought to indicate deficiencies in cognitive processing and emotional regulation, which may contribute to the development or persistence of various medical and psychiatric disorders (Lumley, Neely, Burger 2017).

Linguistic processing problems

Individuals with alexithymia exhibit impaired processing of emotional language at various levels. At a fundamental perceptual level, alexithymic individuals demonstrate reduced sensitivity to the emotional nuances of language. For example, research has shown that compared to low-alexithymic individuals, high-alexithymic individuals exhibit less responsiveness to emotional cues in language contexts (Suslow and Junghanns 2002).

Moreover, alexithymic people have problems with perceiving and interpreting speech prosody, which refers to the melody or intonation of speech that conveys emotional content. Alexithymia may be associated with a generally blunted neural response to speech prosody. Such restricted prosodic processing may contribute to problems in social communication associated with this personality trait (Goerlich-Dobre et al. 2014).

At a communicative level, alexithymic individuals exhibit difficulties in both expressing and understanding emotional language. Research has shown that these individuals struggle to discuss interpersonal relationships (Meganck et al. 2009), articulate the emotional experiences of others (Bydlowski et al. 2005), and understand the emotions of those around them Moriguchi et al. 2006; Swart et al. 2009). Additionally, in personal narratives, alexithymic individuals tend to use simplistic language and lack vivid descriptions when discussing their emotions (Meganck et al. 2009). This condition is also associated with concrete thinking and a tendency to avoid the use of metaphors. (Kreitler 2002).

Physical and behavioural symptoms

Physical symptoms like stomach ache, headaches, or other bodily discomfort can be common companions for alexithymic people.

Alexithymia is associated with heightened physiological arousal, the tendency to notice and report physical symptoms, and unhealthy compulsive behaviours (Lumley, Neely, Burger 2017). The difficulty to connect with others on an emotional level, may leading alexithymics to turn to coping mechanisms such as overeating, substance abuse, or other escapist routines.

Causes and Risk Factors

Previously, alexithymia was linked to a reduced interhemispheric brain connection. From a childhood traumatic perspective, the right prefrontal cortex and the default mode network would undergo alterations, initially hypermetabolic (dysregulation of dopamine and glutamate), and then hypometabolic-dissociative (serotonergic and opioid dysregulation), leading to a distorted interoceptive and emotional awareness. Additionally, structures like the amygdala (responsible for facial expressions and emotional reactivity), the insula (interoception, emotional integration, and empathy), and the cerebellum (specifically the limbic cerebellum and somatosensory awareness) are also implicated in alexithymia (Concha et al. 2017).

Studies in molecular genetics have identified genetic variations in genes related to the serotonin transporter, enzymes involved in dopamine metabolism, and brain-derived neurotrophic factor.

Several theories propose a causal relationship between atypical interoception and specific psychiatric disorders, suggesting that it may represent a transdiagnostic impairment across disorders characterised by reduced perception of one's own emotions, such as alexithymia:

Alexithymia may stem from an inaccurate or atypical perception of internal bodily signals (interoception), which provide information about one's affective state (Brewer et al. 2016; Ernst et al. 2014; Scarpazza et al. 2015). Murphy, Catmur, and Bird (2018) suggest that alexithymia reflects a multidomain, multidimensional failure of interoception. This idea is consistent with theories suggesting that atypical interoception may underpin both symptom commonalities between psychiatric disorders and heterogeneity within disorders. However, the relationship between alexithymia and interoceptive abilities is difficult to determine due to the limited validity of measures used in most studies (Murphy et al., 2018; Trevisan et al., 2019). It is believed that interoceptive signals alone cannot fully explain the complexity of human emotional experiences (Khalsa et al., 2018; Quigley et al., 2021). This suggests that alexithymia may result from atypicalities in systems beyond interoception.

Quattrocki and Friston's (2014) suggest a theory on the role of oxytocin in interoception from multiple perspectives is particularly compelling. They highlight the importance of researching the role of oxytocin in interoception. However, the role of oxytocin in alexithymia remains a topic of debate within the scientific community (Meza-Concha et al., 2017).

Jakobson & Rigby (2021) explored interrelationships between alexithymia and measures assessing how individuals process and regulate their responses to environmental and body-based cues. Whereas externally oriented thinking (EOT) was related to low orienting sensitivity, problems with emotional appraisal (difficulties identifying feelings/difficulties describing feelings) were related to heightened sensory sensitivity. In addition, features of sensory processing sensitivity (SPS) improved the prediction of alexithymia above and beyond that accounted for by interoceptive accuracy (IA). The authors suggest that EOT is linked to problems maintaining a representation of one's emotions in working memory and that low IA and problems with emotional appraisal are linked to atypicalities in sensory processing that may impact embodiment.

Overall, these findings lend support to the view that alexithymia is associated with atypicalities in both bottom-up and top-down processes that impact emotion processing and regulation. They also raise the possibility that individuals with different alexithymia subtypes may differ with regard to a range of factors, including not only sensory processing sensitivity but also early life experiences, mental health outcomes, and susceptibility to various personality disorders.

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[1] alexithymic [from Greek]: “a-“ (without/not/-less) + λέξις [lexis] (word) θυμός [thymos] (soul) – lacking words from the soul (i.e., no words for “emotions/feelings”).

[2] Externally oriented thinking (EOT) is a concrete cognitive style in which individuals focus on the external environment, rather than examining their own internal feelings. Those who exhibit EOT may struggle to acknowledge their emotions and inner states, lack curiosity about their internal experiences, rely heavily on external markers to define their place in the world, and seek validation from sources such as peers, parents, experts, and competitors.

[3] The 20-item Toronto Alexithymia Scale (TAS; Bagby et al. 1994; Parker et al. 2003) is a self-report questionnaire that measures the three core facets of alexithymia: difficulties identifying feelings, difficulties describing feelings, and externally-oriented thinking. A 25-year review has concluded that the TAS-20 demonstrates good reliability and factor validity in a wide range of sociocultural and language settings (Bagby et al. 2020).

The Bermond-Vorst Alexithymia Questionnaire (BVAQ; Bermond et al. 2018) consists of five subscales of eight items each: emotionalising, fantasising, analysing, identifying, verbalising emotions.