Alexithymia

A Case of Deficits in Emotional Intelligence

Graphics courtesy of Neuro ClasticOpens in new window

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.

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.

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.

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.

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.