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Alexithymia

A Case of Deficits in Emotional Intelligence

Alexithymia Graphics courtesy of Neuro ClasticOpens in new window

Alexithymia—the inability to identify and describe emotions—is diagnostically defined as a deficit in the self-awareness of emotions that results in difficulties in the regulation of emotions and particularly a reduced emotional and fantasy life and difficulty in identifying, understanding, and describing the emotion of one’s self and other people.

The term was coined from the Greek for “lack of” (a-), “words” (lexis), and “emotions” (thymos), so it literally means “lack of words for emotions”. However, the literal meaning is misleading because the designated patients can describe their emotions with words, although not with much depth of understanding.

In other words, they lack insight into the causes, significance, and regulation of emotions. Essentially Alexithymia refers to a deficit in intelligence about the understanding and regulation of emotions.

The syndrome was first described when Peter Sifneos and John Nemiah observed that many of their patients with somatizing disorders Opens in new windowhad so much difficulty talking about their emotionsOpens in new window that they did not respond well to insight-oriented psychotherapy.

These patients also usually had other common features, including a stiff posture, an externally oriented focus on concrete functional details, and a barren fantasy and dream life with little emotional content. Subsequently extensive research has shown that alexithymia can be reliably measured, is distinct from other measures of personality, and is associated with increased risk of somatizing and dissociative disorders more than other mental or physical disorders.

A fuller description of the deficits in emotional intelligence in people with alexithymia is presented in Table X-1. It is useful for purposes of assessment and treatment planning to organize these diverse features according to the five planes of self-aware consciousness that have evolved in a stepwise manner in human beings.

Table X-1. Features of Alexithymia Grouped According to Planes of Self-Awareness
Sexual plane (physical sensations and fantasy)
  • Stiff, wooden posture
  • Difficulty distinguishing between bodily and emotional feeling
  • Dreams and fantasies are few, mundane, and unimaginative
  • Difficulty identifying different types of feelings
  • Anxieyt about the significance of feelings
Material plane (motivational drives)
  • Lack of pleasure seeking
  • Narrow, repetitive focus of interests
  • Low frustration tolerance, overwhelmed by practical tasks
  • Limited understanding of causes of emotions
  • Difficulty describing own emotions
Emotional plane (affective attachments)
  • Lack of capacity for enjoyment
  • Unable to appreciate beauty in art or nature
  • Lack of empathy and understanding of feelings of others
  • Awkward and/or detached in social relationships
Intellectual plane (emotional communication and symbolization)
  • Concrete, chronological thinking without emotional contextual analysis
  • Lack of mindfulness about emotions of self and others
  • Lack of symbolization
  • Lack of achievement and creativity
Spiritual plane (sentiments)
  • No sentiment of awe about natural wonders and mysteries
  • No sentiment of connectedness with nature or other people
  • No sentiment of reverence for anything sacred
  • No sentiment of unity and integrating in thinking

The five planes of self-aware functioning of the body can be distinguished by distinct roles in processing physical sensations (in the sexual plane), motivational drives (in the material plane), affective attachments (in the emotional plane), emotional communication and symbolization (in the intellectual plane) and subtle sentiments like awe and compassion (in the spiritual plane).

The corresponding content of these planes for thougth and for the psyche is described elsewhere, but in discussing somatizing and dissociative disorders we must focus primarily on the awareness of the body.

People with alexithymia often have personality disorders, but not all patients with personality disorders are alexithymic. In particular, patients with antisocialOpens in new window and borderline personalityOpens in new window disorders are often highly alexithymic.

More generally, scores on the Toronto Alexithymia Scale (TAS)Opens in new window are moderately correlated with all three dimensions of character of the Temperament and Character Inventory (TCI)Opens in new window. The strongest relations are between the TAS subscale for externally oriented thinking and the TCI scale for material aspects of self-transcendence (self-forgetfulness). Such individuals are slow to become self-aware of physical sensations.

People with alexithymia are also at higher risk for somatizing disordersOpens in new window, substance dependenceOpens in new window, depressionOpens in new window, and particular psychosomatic disorders, such as hypertensionOpens in new window, irritable bowel syndromeOpens in new window, and fibromyalgiaOpens in new window.

For example, patients with fibromyalgia are higher in alexithymia and have greater anxiety and inwardly directed anger than healthy controls. Such findings suggest that alexithymics experience emotional stimuli in the normal physiological ways (e.g., tense muscles, peristaltic contractions) but are unable to identify and interpret them insightfully in self-awareness.

Not knowing the emotional significance or cause of the sensations, somatizing patients interpret them incorrectly as symptoms of physical illness and feel sickly. The associated distress may set up a vicious or downward spiral of somatic anxiety.

Alexithymia interferes with talk therapies that require facility with uncovering and describing emotions and that are anxiety-provoking. Therefore, appropriate therapies require promotion of calmness and communication in the language of the body.

Treatments of choice based on our clinical experience and available research are presented in Table X-2 along with the corresponding target problem in chronic somatizing and dissociative disorders. Treatment recommendations are sometimes made for complex protocols in which it is unclear what is being done and for whom. Some forms of mindfulness therapy, cognitive behavioral therapy (CBT)Opens in new window, or eye movement desensitization and reprocessing (EMDR)Opens in new window are useful for some symptoms of some somatoform patients, but it is unclear what therapeutic elements are useful for particular symptoms of particular patients.

Indicators of Elevated Body Self-AwarenessMethods for Elevating Body Self-Awareness
Sexual plane
  • Fluid and expressive body movement
  • Facility identifying emotions
  • Imaginative fantasy and dreams
  • Gymnastics and yoga
  • Expressive dance
  • Body remodeling and acupuncture
Material plane
  • Broadening of interests and sources of satisfaction
  • Non-violent assertive communication
  • Individualized healthy diet for body type and balancing cravings
  • Compassionate communicating training
Emotional plane
  • Appreciation of beauty in art and nature
  • Empathy and understanding others feelings
  • Experiencing beautiful artistic creations
  • Active listening and empathy training
Intellectual plane
  • Psychoeducation about temperament and conflict resolution with self and others
  • Psychodrama and group therapy
  • Personal engagement in communication
Spiritual plane
  • Awareness of subtle sentiments and self-transcendent values:
  • Awe about mysteries and wonders
  • Connectedness with nature
  • Abnegation of self-respect and compassion for others
  • Reverence for sacred things
  • Union with nature meditation
  • Personal engagement in self-transcendent activities
Table X-2. Experiential methods for elevating emotional intelligence in chronic somatoform and dissociative disorders, that is, of reducing alexithymia by elevating self-awareness of the body and its sensations, drives, emotions, and sentiments (Cloninger and Cloninger, 2011) and the Know Yourself © well-being coaching program of the Anthropedia Foundation).

In the past treatment of somatizing patients, results have often been incomplete with much refusal of psychiatric treatment, frequent drop-out, and week to moderate results of those retained.

We have found it important, therefore, in developing and optimizing treatment methods fro individual patients to relate what is done to specific target signs and symptoms, as in Table X-2. For example, improved fluidity and expressivity of body movements can be facilitated by gymnastics and expressive dance. Physical therapies and exercises are beneficial in randomized controlled trials of a variety of chronic somatizing disorders.

Greater awareness of one’s body and enjoyment of a healthier diet can be facilitated by individualized diets that require awareness of body type and food cravings like what has long been done in Ayurvedic medicine. Training in non-violent assertive communication can be explained in a concrete way to facilitate more effective self-expression.

Methods for identifying emotion can be taught, beginning with listening to verbal and physical cues, and then learning to resolve conflicts without personal criticism or sarcasm.

A training program has also been developed to assist well-being coaches and therapists to teach an understanding of emotional processes and specific meditations that enhance sensory awareness, appreciation of beauty, empathy, and the principles of well-being.

The promotion of health through increased self-awareness is applicable to a wide range of people, including individuals with deficits in any form of self-awareness, including alexithymics and chronic somatizing patients.

The methods described in Table X-2 are designed for long-term treatment of chronic patients and additional methods are needed for intervention with acute patients, such as acute conversions or fugues.

The methods of Table X-2 are focused on elevating self-awareness of the body’s sensations, motivational drives, emotional attachments, emotional symbols, and sentiments.

These are what we label as the components of the body that can be elevated in self-aware consciousness, bringing what has been lost down in the unconscious up into conscious self-awareness.

In contrast, the procedures recommended for acute patients are directed at what we label as the “body component of thought”: namely,

  • feelings of self-respect,
  • self-mastery,
  • intimacy,
  • capacity to work through mental trauma, and
  • the spirit of self-sacrifice.

These cognitive phenomena require different treatment methods. In particular, the therapy is directed at somatic aspects of thought so the quality of therapist’s relationship to the patient is crucial.

Without words, the therapist must relate directly to the patient with hope, compassion, and faith while helping the patient find ways they can learn the art of living well. This quality of compassion provides appeasement, rather than provoking anxiety, frustration, or other forms of negative emotion, in both the patient and the therapist.

In the context of this kind of therapeutic relationship, the patient can be helped to reconcile emotional conflicts in each realm of their life, as described in Table X-3.

Indicators of elevated
body component of thought
Treatments of choice
Feelings of self-respect
  • Therapist’s hopeful validation
  • Reconciliation of conflicts between extremes of Harm Avoidance (anxiety versus risk-taking)
  • Cardiac coherence
  • Physical exerices for fitness
Feelings of impulse control and self-mastery (ability to delay gratification, responsibility, purposefulness)
  • Therapist’s forgiveness and kindness
  • Reconciliation of conflicts between extremes of Novelty Seeking (impulsive versus rigid)
  • Goal-settign and accomplishment
Feelings of intimacy and security in social attachments
  • Therapist’s spiritual appeasement
  • Reconcialiation of conflicts between extremes of Reward Dependence (approval versus privacy seeking)
  • Engagement in social activities
Retentive and flexible working memory
  • Therapist’s non-judging patience
Capacity to work through mental trauma calmly
  • Reconciliation of conflicts between extremes of Persistence (perspective versus impersistent)
  • Eye movement desensitization and integration for trauma
Spirit of self-sacrifice
  • Therapist’s integrated intelligence
  • Union in nature medication 3x/day
  • Engagemetn in self-transcendent activities
Table X-3. Experiential methods for elevating the body component of thought in acute somatizing and dissociative disorders (e.g., conversion or fugue).

When possible, graded physical exercise can be both relaxing and helpful in building self-respect and fitness, as has been shown in randomized controlled trials of patients with complaints of fibromyalgiaOpens in new window and chronic fatigue. Particular somatic methods are helpful in dealing with the effects of mental trauma and stress according to randomized controlled trials; these include eye movement desensitizatiojn, cardiac coherence, supplementing diets with omega-3 fatty acids for brain fluidity, and others.

Group therapy has been shown in a randomized controlled trial to improve physical and mental health in Somatization Disorder for at least a year after treatment. In addition, a meditation on Union with Nature in which a person increases their awareness of sensations from all five of their special senses is particularly useful but needs to be practiced for 30 minutes at least three times daily following mental trauma like those typically associated with acute conversions or fugues in order to allow de-stressign of the limbic system. This meditation is a means of enhancing sensory awareness to bring satisfaction and joy from everyday natural experiences of everyday life like walking, eating, smelling, hearing, and seeing.

See also:
  1. Bermond, B., Vorst, H.C.M., & Moormann, P.P. (2006). Cognitive neuropsychology of alexithymia: Implications for personality typology. Cognitive Neuropsychiatry, 11 (3), 332 – 360.
  2. Fitzgerald, M., & Bellgrove, M.A. (2006). The overlap between alexithymia and Asperger’s syndrome. Journal of Autism and Developmental disorders, 36(4), 573 – 576.
  3. Levant, R.F. (2004). Assessing and treating normative male alexithymia. In G. P. Koocher, J.C. Norcross, & S.S. Hill (Eds.), Psychologists desk reference (pp. 278 – 281). Cary, NC: Oxford University Press.
  4. Fukunishi, I., Berger, D., Wogan, J. & Kuboki, T. (1999). Alexithymia traits as predictors of difficulties with adjustment in an outpatient cohort of expatriates in Tokyo. Psychological Reports, 85 (1), 67 – 77.
  5. Haviland, M.G., Warren, W.L. & Riggs, M.L. (2000). An observer scale to measure alexithymia. Psychosomatics, 41(5), 385 – 392.
  6. TenHouten, W.D., Hoppe, K. D., Brogen, J.E., & Walter, D.O. (1986). Alexithymia: An experimental study of cerebral commissurotomy patients and normal control subjects. American Journal of Psychiatry, 143, 312 – 316.
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