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The only emotions I can feel are anger and fear

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Stephen has been married twice. Two wedding days. Two "I do"s. Yet Stephen has no happy memories from either - or, in fact, from the marriages or any of his relationships.

He met his first wife on a pre-nursing course when he was just 16. Six years later, they were married. Three years after that, they got divorced; she was never really the right one for him, he says. Almost two decades on, in 2009, he met his second wife through a dating site. He threw himself into the relationship and, the following year, with his father and her two adult siblings present, they married at the registrar's office in Sheffield, where they both live.

He put on smiles for the wedding photos because he recognised that they were expected but, as he explains: "From an inner feeling point of view, anything I do that requires an emotional response feels like a fake. Most of my responses are learned responses. In an environment where everyone is being jolly and happy, it feels like I'm lying. Acting. Which I am. So it is a lie."

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Happiness isn't the only emotion that Stephen struggles with. Excitement, shame, disgust, anticipation, even love... he doesn't feel these, either. "I feel something but I'm unable to distinguish in any real way what that feeling is." The only emotions he is familiar with are fear and anger.

Such profound problems with emotion are sometimes associated with autism, which Stephen does not have, or with psychopathy, which he doesn't have, either. Last year, at the age of 51, he finally learned what he does have: a little-known condition called alexithymia, a word made from Greek parts meaning, roughly, "no words for emotion".

Despite the name, the real problem for people with alexithymia isn't so much that they have no words for their emotions, but that they lack the emotions themselves. Still, not everyone with the condition has the same experiences. Some have gaps and distortions in the typical emotional repertoire. Some realise they're feeling an emotion, but don't know which, while others confuse signs of certain emotions for something else - perhaps interpreting butterflies in the stomach as hunger pangs.

Surprisingly, given how generally unrecognised it is, studies show that about one in ten people fall on the alexithymia spectrum. New research is now revealing what's going wrong - and this work holds the promise not only of novel treatments for disorders of emotion, but of revealing just how the rest of us feel anything at all.

After working as a nurse for ten years, Stephen decided he wanted to do something different. A two-year Access to University course led to a degree in astronomy and physics, and then to a job testing computer games. He built a successful career for himself, working for various companies in their computer testing departments, managing teams, and travelling around the world to speak at conferences. He had no problem conveying facts to colleagues. It was in the context of more personal relationships - or any other scenario that would typically involve expressions of emotion - that he felt things were "wrong".

"At the beginning of a relationship, I'm totally into who that person is," he explains. "I've been told I'm very good at maintaining a honeymoon period for 'longer than expected'. But after a year it takes a massive turn. It all falls apart. I've put myself on a pedestal to be this person which I'm really not. I react mostly cognitively, rather than it being emotions making me react. Obviously, that is not valid. It's not real. It seems fake. Because it is fake. And you can only pretend for so long."

He and his current wife stopped living together in 2012. He saw a GP and was prescribed antidepressants. Though he was still in contact with his wife, it was clear that the relationship was no longer working. In June 2015, he attempted suicide. "I had actually been posting on Facebook and Twitter regarding killing myself, and someone - I've never found out who - contacted the police. I was taken to hospital and treated."

A psychiatrist referred Stephen for a series of counselling sessions and then a course of psychodynamic psychotherapy, a type of Freudian-based therapy that, in trying to uncover unconscious drivers of thoughts and behaviour, is similar to psychoanalysis.

It was in a book called Why Love Matters by Sue Gerhardt, which his therapist recommended, that he first came across the concept of alexithymia. "I brought it up in therapy, and that's when we started talking about how I was very alexithymic. Obviously, I've got a vocabulary. I've got words for emotions. But whether they're the right words for the right emotion is a different point altogether... I just thought that I wasn't good at talking about how I feel and emotions and stuff like that. But after a year of therapy, it became apparent that when I talk about emotions I don't actually know what I'm talking about."

The term "alexithymic" dates from a book published in 1972 and has its origins in Freudian psychodynamic literature. Freudian ideas are now out of favour with most academic psychologists, as Geoff Bird, a professor of psychology at the University of Oxford explains. "Not to disrespect those traditions, but in the cognitive, neuro, experimental field, not so many people are really very interested in anything associated with Freud any more."

But when Bird read about alexithymia, he found the descriptions intriguing. "Actually, it's really quite amazing." For most people, "at a low level of emotion, you might be a bit unsure about exactly what you're feeling, but if you have a strong emotion, you know what it is". And yet somehow, here were people who simply did not know.

Bird started his academic career studying autism spectrum disorder, empathy and emotional awareness, which led to his interest in alexithymia. In one of his first studies in this field, he linked alexithymia, as measured with a 20-item checklist developed at the University of Toronto, with a lack of empathy. If you can't feel your own emotions in the typical way, it makes sense that you can't identify with those of others, either.

But what really drew Bird into alexithymia research were his interactions with people with autism. "There has been this perception that people with autism don't have empathy. And that's rubbish. And you can see that immediately as soon as you meet some autistic people."

In a series of studies, Bird has found that about half of people with autism have alexithymia - it's these people who struggle with emotion and empathy, while the rest do not. In other words, emotion-related difficulties are intrinsic to the alexithymia, not to the autism.

Bird is passionate about spreading this message. He talks with feeling about one particular autistic study volunteer who did not have alexithymia: "A lovely guy with an IQ we couldn't measure, it's that good. He couldn't hold down a job. But he volunteered to work at a care home because he wanted to do something productive with his time. They said, 'Oh because you've got a diagnosis of autism you can't do empathy, therefore you can't look after our elderly people.' Which is just ridiculous."

Bird has since run a series of studies exploring alexithymia outside the context of autism. He has found, for example, that people with the condition have no trouble recognising faces, or distinguishing pictures of people smiling and frowning. "But for a few of our really alexithymic people, while they can tell a smile and a frown apart, they have no idea what they are. That is really quite strange."

Many of the people with the condition who Bird has met talk about being told by other people that they're different, though some do recognise it in themselves early on. "I guess it's a bit like not being able to see colour, and everybody's always banging on about how red this is or how blue, and you come to realise there's an aspect of human experience that you're just not participating in."

As well as better characterising alexithymia, Bird and his colleagues have also dug into what explains it, taking what could seem to be a circular argument - Stephen has problems with emotion because he has alexithymia, which is characterised by problems with emotion - and blowing it right apart.

In situations that Stephen recognises as being in theory highly emotional - like telling someone "I love you" - he experiences changes inside his body. "I feel my heart race and this rush of adrenaline, but to me that feeling is always scary. I don't know how to react. It makes me want to either run away or react verbally aggressively."

Fear and anger - and confusion - he understands. "Everything else just feels all the same... it's this feeling of, 'Errrr, I'm not quite comfortable with this - it's not quite right.'"

For Rebecca Brewer, a former student of Bird's and now a lecturer at Royal Holloway, University of London, this makes sense. "With alexithymia, people often know that they are experiencing an emotion but don't know which emotion it is," she explains. "This means they could still experience depression, possibly because they struggle to differentiate between different negative emotions, and struggle to identify [positive] emotions. Similarly with anxiety, it might be that someone experiences an emotional response associated with a fast heartbeat - which might be excitement - but they don't know how to interpret that, and they could panic about what's happening in their body."

The ability to detect changes inside the body - everything from a racing heart to a diversion of blood flow, from a full bladder to a distension of the lungs - is known as interoception. It's your perception of your own internal state.

Different emotions are associated with different physical changes. In anger, for example, the heart rate rises, blood rushes to the face, and fists clench. In fear, the heart rate also rises but blood drains from the face. It's generally thought that these changes are not entirely specific to individual emotions, and so context is also important: if you feel your heart racing and you're looking at a spider, you know it's fear that you're feeling, not sexual arousal.

What Bird, Brewer and others have found in people with alexithymia is a reduced ability, sometimes a complete inability, to produce, detect or interpret these internal bodily changes. People with the condition have normal-range IQs. They can understand as well as anyone else that they're seeing a spider, rather than an attractive potential partner. But either their brains aren't triggering the physical changes that it seems are needed for the experience of an emotion, or other regions of their brains aren't reading these signals properly.

In 2016, Bird and Brewer, along with Richard Cook at City University in London, published a research paper that characterised alexithymia as a "generalised deficit of interoception". Here, then, was an explanation for these people's problems with emotion - but also, in effect, a manifesto stating that the perception of a range of bodily signals is important for the experience of emotion in the rest of us.

It's an idea that we already express in everyday language: in English, for an apology to mean anything, it has to be "heartfelt". If you truly love someone, it's with "all your heart". When you're really angry, your "blood boils". Instead of saying that you're anxious, you might talk about having "butterflies in your stomach" (thought to be caused by a diversion of blood flow away from the digestive system).

While most people may not be familiar with alexithymia, there is a different disorder involving flat emotions and poor empathy that seems to fascinate us, even more than it repels us: psychopathy. Can we learn more about how we feel by understanding psychopaths?

Lieke Nentjes is in her early 30s. She's slender and softly spoken; it's hard to picture her spending countless hours in small rooms with incarcerated, unshackled psychopaths, including serially violent men who have committed murder.

As Nentjes talks, though, she reveals her confidence. "One time, there was this pretty big fella with wild, long hair sat across from me, and he suddenly said [raising her voice and half getting up from her chair]: 'Aren't you afraid of me?' I was surprised. I didn't see that coming. And I went [not raising her voice, but strengthening the tone]: 'Why - are you afraid of me?' And he sat back down. Then he explained that he was at the end of his therapy and was 're-socialising' and no one would hire him because they were intimidated by him. He wasn't really angry. He was frustrated."

While the nature of psychopathy is still debated, psychologists generally agree that it entails, among other things, a lack of empathy or guilt, shallow emotions, and antisocial behaviour - treating other people badly and, in some cases, engaging in criminal acts.

It has certainly been suggested that the reason some psychopaths are able to torture or murder people is that they don't process emotions properly - they don't feel fear, for example, and they don't recognise it in others.

Nentjes is based at the University of Amsterdam. Here in the Netherlands, if a criminal is found to have a psychological condition that relates to the crime, he or she is deemed to be only partially responsible. Such criminals might spend a few years in a regular jail before being sent to a secure treatment centre, or they may be sent straight for treatment.

Nentjes decided to assess a range of criminals from these centres and from jails to find out just how psychopathic they were (with particular attention to different aspects of psychopathy), to learn about their lives - their upbringing, and their criminal behaviour - and also to measure their interoceptive ability.

"Emotion is very central when you look at psychopathy - or rather, lack of emotion," she says. "So could it be that psychopathic offenders just aren't very in touch with their bodies?

In the course of the interviews, Nentjes asked questions to probe their levels of empathy, and how much remorse they felt about what they had done to their victims. "Some were just completely honest, and would say, 'I don't care,'" she says. "Others who were psychopathic would say, 'Oh, but I'm very empathic.' They had learned the lingo to describe feelings very accurately and they could talk about compassionate, empathic feelings towards others - but then when you look at the crimes they have committed..." Her sentence trails off.

"There is research finding that psychopathic offenders can describe emotions in terms of words, but they lack the inner experience of the emotion," she adds.

Since assessing a person's ability to detect a range of bodily signals is tricky, the most commonly used measures of interoceptive sensitivity are based on judgements of heart rate. One test involves asking participants to count their heartbeats over varying periods - 25 or 50 seconds, perhaps - multiple times. About 10 per cent of us are good at counting heartbeats, 5 to 10 per cent are very bad, and the rest fall somewhere in between.

In another test, volunteers are played a series of beeps that are either in sync or out of sync with their heartbeat, and asked which it is. On this type of task, about 10 per cent of the general population can do it really well, and 80 per cent can't do it at all.

Nentjes brought the necessary equipment for the heartbeat sync task with her into the interview rooms, and took measures for 75 offenders. She found a clear link: the higher an offender's score on the antisocial aspect of psychopathy, the poorer their performance on the heart-rate task. This does at least suggest that psychopaths who are poorer at detecting bodily signals feel less emotion and therefore less empathy for others.

Psychopathic criminals are sometimes divided into the 'white-collar' type, who tend to commit non-violent crimes such as fraud, and the violent type. In her interviews with this violent group, Nentjes was struck by one similarity, in particular, compared with the white-collar group: "That was their upbringing. Or rather lack of it. Emotional abuse. Sexual abuse. Neglect. A lot of physical abuse. I've heard people literally say that emotion is not of use to them. All they felt during their upbringing was fear."

As a child, Stephen suffered extreme emotional neglect. When he was six, his mother intentionally set fire to their home in Nottingham while she, Stephen, his younger brother and even younger sister were all inside. Fortunately, the children's father, who had left for work, realised that he'd forgotten his packed lunch and came home.

Looking back, Stephen says it's clear that his mother was suffering from post-natal depression. But she received no treatment, "and all I knew was anxiety and being worried". After the fire, his mother went to prison. His father was a steelworker, who worked all kinds of shifts. "A neighbour contacted social services and Dad was told to sort it out or they'd take us away. None of my dad's brothers or sisters wanted me or my brother because we were little shits. We were always in trouble. Robbing shops. All kinds of stuff. So we went into care."

For the rest of his childhood, Stephen was in and out of care homes. The only emotions he remembers feeling, even then, are fear, anger and confusion. "Christmas, birthdays, people out of the blue at care homes being nice to me... I never really got used to it. I always felt uncomfortable. There's just a mess of feelings inside me that I don't interpret properly, or respond to properly."

Alexithymia is often associated with trauma and neglect from a young age, explains Geoff Bird. Twin studies have suggested a genetic component, too. And it's also linked to certain types of brain damage, particularly to the insula, the region that receives interoceptive signals.

As Rebecca Brewer notes, the kind of anxiety that Stephen experiences is common in people with poor interoception. At the University of Sussex, Hugo Critchley and Sarah Garfinkel, who have expertise in psychiatry and neuroscience, are looking at ways to alter interoception, to bring anxiety down.

Garfinkel has put forward a three-dimensional model of interoception that has been well-received by others in the field. First, objective accuracy at perceiving interoceptive signals - how good you are at counting heartbeats, for example. Second, subjective report - how good you think you are. And third, metacognitive accuracy - how good you are at knowing how good you actually are.

The third dimension is important because various studies have found that the gap between how good someone thinks they are at counting heartbeats, for example, and how good they actually are predicts their levels of anxiety. Lisa Quadt, a research fellow with the Sussex group, is now running a clinical trial with the aim of testing whether reducing this gap for people with autism can reduce their anxiety.

In a pilot study, Critchley, Garfinkel and MSc student Abigail McLanachan recruited a group of students who came into the lab for six training sessions. In each session, they first did the heartbeat-counting task. The volunteer sat at rest, with a loose rubber pulse oximeter on their forefingers, and reported how many beats they'd counted. Then McLanachan told them how they'd done so that they got a better sense of how accurate they were.

McLanachan then got them to do a few minutes of jumping jacks or walking fast up the steep hill outside the building - whatever was necessary to raise their heart rate, to make it easier to detect. ("Because some people really can't feel their heartbeat at all. I can't," Quadt explains.) Then they went back into the lab, did the tasks again and, as before, were given feedback each time.

This was just a pilot study on a general student population. But after three weeks, not only had the students' accuracy improved on all three dimensions of interoception, but they also reported reductions in anxiety of around 10 per cent.

For the main trial, volunteers diagnosed with autism spectrum disorder will complete the same tasks as in the pilot, but once at the start and once at the end they'll do them inside an fMRI scanner. This will allow the team to monitor activity in the insula, which receives heart-rate data, and look at how changes in that activity may correspond to connections between the amygdala, which detects threats, and the prefrontal cortex, which can work out whether a potential threat really is or is not dangerous and so whether anxiety is warranted. The hope, Critchley explains, is to see improved connectivity between these two regions, which previous studies have linked to reduced anxiety.

In Oxford, meanwhile, Geoff Bird wants to look at the idea that there are two different types of alexithymia. People with one type don't produce enough of the bodily signals necessary for the experience of an emotion, so would be unlikely to benefit from the Sussex group's kind of training. People with the other type produce all kinds of bodily sensations but their brains don't process these signals in the typical way. This second group, which includes Stephen, might benefit more.

Bird stresses that, although people with alexithymia struggle to understand emotion, that doesn't mean they don't care about other people. "For the most part, individuals with alexithymia can recognise that others are in a negative state, and this makes them distressed. The problem is that they can't work out what the other person is feeling, and what they are feeling, and therefore how to make the other person feel better or how to reduce their own distress. I think that's important because alexithymia is different from psychopathy in that respect."

Stephen says that for him, this is certainly true. And in theory, an emotional training technique is something he would welcome. "I've got several books about emotions and feelings and they don't make a jot of difference because they're not talking specifically enough about what you actually feel within your body is which emotion."

For now, given the absence of available treatments for alexithymia, Stephen plans to use his newfound understanding of himself, gained through therapy, to try to move forwards. At first, he says, he hoped that therapy would fix everything. "I thought every day would be perfect, brilliant... and I've come to realise that's not going to happen. I'm always going to have problems, always going to have issues."

He's learned valuable lessons, he says. Though he and his wife are still separated, they talk regularly and now he tries not to reject her views on his anxiety. "Rather than go, 'No,' I will listen. I think, 'Well, you know what emotions are about and I don't, so I'm going to listen to you and I'll either take it on board or I'll find a way to deal with it.'" He's also thinking about moving to work with people who are struggling with substance abuse, because he'd like to be back in a career where he can help people.

Most of all, he's determined to use his diagnosis of alexithymia. "For me, it empowers me - now I know about it, I can read about it. I can find out more about it. And I can develop certain tools that enable me to combat it."

People without alexithymia could probably use such tools as well. Bird has led work showing that people who are more aware of their own heartbeat are better able to recognise others' emotions, a crucial first step in being empathetic. He's planning studies to investigate whether heartbeat training might therefore increase empathy.

Those who want to reduce feelings of stress and anxiety in daily life, but who either can't or don't want to change the sources of stress, could focus on changing the signals coming from their bodies instead. Regular physical exercise should dampen down the kinds of bodily signals (from the heart and circulation, for example) that the brain could interpret as being anxious - so it should dampen down feelings of anxiety, too.

Knowing that signals from our bodies underpin our emotions could be empowering for all of us. Now, how does that make you feel?

References

This 2016 paper by Rebecca Brewer, Richard Cook and Geoff Bird is a good introduction to alexithymia and its relation to interoception.

Sarah Garfinkel's three-dimensional model of interoception was described in a 2014 paper in Biological Psychology.

A 2013 article by Bird and Cook explains how alexithymia is not necessarily part of autism and can be associated with various other conditions too.

Childhood trauma is often associated with later psychological conditions such as depression and alexithymia.

Researchers think we can learn a lot about emotion by studying psychopaths, who tend to have low empathy, guilt and remorse.

In the UK and Republic of Ireland, the Samaritans can be contacted on 116 123. In the USA, the National Suicide Prevention Lifeline is 1-800-273-TALK.

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The only emotions I can feel are anger and fear

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Stephen has been married twice. Two wedding days. Two "I do"s. Yet Stephen has no happy memories from either - or, in fact, from the marriages or any of his relationships. He met his first wife on a pre-nursing course when he was just 16. Six years later, they were married.

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Be A Man: Joe Ehrmann at TEDxBaltimore 2013

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Alexithymia is a personality construct characterized by the subclinical inability to identify and describe emotions in the self. The core characteristics of alexithymia are marked dysfunction in emotional awareness, social attachment, and interpersonal relating. Furthermore, people with alexithymia have difficulty in distinguishing and appreciating the emotions of others, which is thought to lead to unempathic and ineffective emotional responding.

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Date: 2015/08/22 (Rev. 2018/08/22)

Thomas C. Weiss - Disabled World

Synopsis : Information regarding alexithymia including signs, symptoms and possible treatment options for alexithymia.

What is Alexithymia?

Alexithymiais is defined as a personality construct characterized by the sub-clinical inability to identify and describe emotions in the self. The core characteristics of alexithymia are marked dysfunction in emotional awareness, social attachment, and interpersonal relating. Furthermore, individuals suffering from alexithymia also have difficulty in distinguishing and appreciating the emotions of others, which is thought to lead to un-empathic and ineffective emotional responding.

There are two types of alexithymia, trait and state:

State alexithymia has a specific cause is is often a temporary condition. Post-traumatic stress disorder, caused by experiencing a horrifying event, is one example that is known to trigger this type of alexithymia.

Trait alexithymia is believed to be a characteristic inherent in a person's personality. Trait alexithymia may be, 'inborn,' or caused by events that happen in a person's early childhood such as neglect or abuse from a primary caregiver.

Alexithymia is prevalent in approximately 10% of the general population and is known to be comorbid with a number of psychiatric conditions. In studies of the general population the degree of alexithymia was found to be influenced by age, but not by gender; the rates of alexithymia in healthy controls have been found at: 8.3%; 4.7%; 8.9%; and 7%. Thus, several studies have reported that the prevalence rate of alexithymia is less than 10%.

Understanding and expressing emotions are two parts of the human experience that may be confusing for a number of people. Learning more about possible causes for a person's experience of feeling less than average emotionally and maybe asking questions to trusted professionals might help to find a way to narrow down possible solutions. What follows is more information about alexithymia to help explore the signs, symptoms and possible treatment options for alexithymia.

Symptoms of Alexithymia

'Alexithymia,' is a clinical term for the inability to understand the intricacies of feelings and emotions. The existence and study of alexithymic experiences started in the 1970's. Some research suggest that alexithymia is more predominant in men and it is in women.

Alexithymia is also understood to have two components;

A cognitive component where people might face challenges with thinking and emotions while trying to name, understand and talk about feelings.

An affective component where people might struggle with the experience of sharing, responding to and sensing emotions.

People who experience the effects of alexithymia might notice some different things such as:

A lack of impulse control

Violent or disruptive outbursts

Indifference towards other people

Difficulties with articulating emotions

Difficulties with naming different kinds of emotions

Struggling to identify emotions expressed by others

Heightened sensitivity to sights, sounds, or physical touch

A narrow capacity to understand the reasons behind certain emotions

Alexithymia is not just a lack of interest in emotional connection, it is rooted in psychological and neurological mishaps that can be sources of frustration for people who experience the symptoms as well as people around them. The condition also exists on a spectrum; so for some people the symptoms might interfere more largely in their lives than it does for other people.

Alexithymia and Mental Health

In a number of instances, alexithymia is a symptom of other forms of mental health conditions. To achieve a diagnosis of alexithymic symptoms, a person would need to receive evaluation of and diagnosis of a primary mental health condition. Alexithymia has been observed in people who also have:

Depression

Eating disorders

Substance abuse

Certain brain injuries

Post-traumatic stress disorder

Treating Alexithymia

Treatment of alexithymia may be incorporated into the overall treatment of the person's broader condition. During an evaluation, a clinician will most likely talk with the person affected for a period of time and ask them to complete surveys and additional psychological testing. Based upon the results of the person's psychological evaluation, they will have a better idea of how alexithymic symptoms may be associated with one or more forms of mental health conditions.

The treatment options for alexithymia are often times very different from typical counseling or talk therapy. For people living with alexithymia, a mental health professional will often concentrate on building a foundation of naming emotions and appreciating a range of feelings. The process will likely include both consideration of the experiences of other people and self-reflection. Even though some people with this emotional comprehension might sound very basic to others, for a person with alexithymia the process of growing their emotional intelligence and capacity may be difficult. Things such as:

Group therapy

Daily journaling

Skill-based therapy

Engaging in the creative arts

Various relaxation techniques

Reading emotional books or stories

Might be used to help cultivate skills for identifying and understanding feelings on both a surface and in-depth level. Just as with the majority of mental health or medical concerns, a formal diagnosis and treatment should be done by a mental health professional with expertise in the area. When an affected person feels ready, a licensed mental health professional may be the next best step to help ease any distress the person might be feeling. People with alexithymia need to be patient with themselves as they decide what is best for them as a person.

In the past, alexithymia was classified and limited to psychosomatic disorders, which are disorders involving physical symptoms of the person's body that are created and exacerbated by their mind. For example; a person who is very angry, yet does not express their anger, might develop a stomachache. The condition as a psychosomatic disorder often times manifests in the form of bodily symptoms and complaints of a person who is unable to effectively express their emotions. Research has revealed that it may be present in people who do not experience psychosomatic disorders or physical complaints as well.

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Alexithymia: Information, Symptoms and Treatment Options

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Date: 2015/08/22 (Rev. 2018/08/22) Thomas C. Weiss - Disabled World Synopsis : Information regarding alexithymia including signs, symptoms and possible treatment options for alexithymia. Alexithymiais is defined as a personality construct characterized by the sub-clinical inability to identify and describe emotions in the self.

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"Eric, you absolutely must talk with your wife about this," I said. "You have to tell her you're looking for a condo to buy. You have to let her know that you're leaving her."
"I will. I really will. I'll do it this week. I promise," he insisted.

But as I sat across from Eric in my therapy office, listening to his earnest declarations while synthesizing them with his body language and history, I knew that he would not.

You may be wondering what kind of man plans to leave his wife but does not tell her. Is Eric a narcissist? A cheater? An addict? Or a sociopath?

No, not at all. Eric is none of those things. In fact, he is a devoted family man who has never cheated on his wife. He's not hiding anything from her. He's not secretive or deceptive or uncaring.

Eric's only offense is that he has a severe case of alexithymia.

Alexithymia : The inability to identify and describe your own emotions.

Do you find it easier to communicate by mutual understanding than with words?

Do you get tongue-tied when you're upset?

Does it feel almost impossible to tell someone what you're feeling?

Do you avoid conflict?

Is it a struggle to tell someone you love them?

Does strong emotion make you acutely uncomfortable, even if it's coming from someone else?

Alexithymia may seem like a pretty mild problem in comparison to many others, like depression or anxiety or personality disorder. After all, you may have been able to work around it in many ways, just as Eric had.

But truth be told, I have seen marriages lost, sibling relationships damaged, and children estranged by nothing other than this malady. It is, indeed a thoroughly devastating problem to go through life with.

What Causes Alexithymia?

Over time, scientists have worked to identify the factors that cause some people to suffer with this problem so much more than others. Childhood abuse, neurological deficits and genetics have all been researched and named.

But I have noticed in my work a remarkably high correlation between those who struggle with alexithymia, and a childhood marked by a shortage of parental attention paid to their emotions. When parents don't respond to their children's emotions enough (Childhood Emotional Neglect, or CEN), the children don't learn emotion skills.

This is not to say that abuse, neurology and genetics are uninvolved, especially since we now know that these three factors interact with each other in far more complex ways than we ever before realized.

But it is human nature to get caught up in things that happen (child abuse, in this case) and the physical world (neurology and genetics) to explain things. Often the best answer is the simplest solution:

Sometimes, our parents just don't teach us things.

1. Stop blaming yourself. There is, most likely, nothing wrong with your brain. And it's very possible that your genes are just fine. Your problem is simple, and fixable, and you did not choose it or cause it. All you have to do is be willing to overcome it, and we will talk about that next.

2. Stop struggling in secret. Own this problem for what it is, a skill deficit. Accept that blame and shame have no place in this picture, and tell someone about it. Your partner, a close family member and/or a trained therapist. It's time to start learning what you missed.

3. Begin to learn the emotion skills you missed. As a child, you may have walled off your emotions because of the CEN you experienced. If so, you may be living your adult life wondering where your feelings are. I assure you they are there, and you can access them. Whether your emotions are walled off or not, you can learn how to access, identify, tolerate, manage, and express your feelings.

4. Accept help. As someone who grew up with your emotions under the radar, I suspect that you might be quite self-sufficient and self-contained. But learning the emotion skills you missed is difficult without someone guiding and teaching you. A licensed therapist skilled at teaching how to identify and express emotions can walk you through the learning process.

Childhood Emotional Neglect is often invisible. To find out if you have it, I encourage you to Take the Emotional Neglect Questionnaire (it's free). There, you can also read more about the emotion skills and how you can learn them.
Sadly, it was too late to save Eric's marriage. If only he could have realized years ago that his secret struggle was the product of CEN. If only he had known that it was not a flaw or a defect, as he had always feared. Perhaps he could have learned the skills he missed, and healed his Childhood Emotional Neglect. Perhaps he could have talked, and felt, and communicated, and kept alive the love and closeness that he and his wife once shared. Photo by ChrisHConnelly
Alexithymia: The Cause and The Solution

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Eric "Eric, you absolutely must talk with your wife about this," I said. "You have to tell her you're looking for a condo to buy. You have to let her know that you're leaving her." "I will. I really will. I'll do it this week....

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Two psychologists present their differing theories.

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A recent clinical encounter reminded me of an important point about the way many modern men experience their emotions and needs, and how this can have a dramatic impact on relationship quality and lead to all sorts of confusion and conflict. I have seen the themes unfold in similar ways in many different couples; I recreate a typical scene below.

Alicia*, a nurse practitioner in her mid-40s, entered individual therapy with a doctoral student of mine. She was experiencing high levels of distress, much of it centered on her relationship with Frank, her husband of five years, who worked as a carpenter. Alicia described Frank as having been warm and loving during the first few years of the relationship, but things had gotten bad over the past few years and now he was cold, detached, and prone to angry outbursts. The description was such that we felt it was crucial to see Frank and get his take on the situation. Although Frank was initially very reluctant, he eventually agreed to come in and share his version of reality.

At our initial meeting, he was guarded and resistant. However, by empathizing with his concerns about being ganged up on, and showing him quickly that we could help, by explaining to him why his relationship had gone sour and how it might get better, he bought into the process. It turned out that the therapy was quite successful in turning the vicious cycles around, and much greater levels of relational satisfaction and well-being returned to Frank and Alicia in a month or so.

One major issue that had to be addressed early was a fairly common one, especially with "traditionally masculine" men. It is what former APA president Ron Levant called "normative male alexithymia."

Before I define the term, consider the following exchange which took place during our first session: I had met individually with Frank for about 30 minutes, and had a sense of where he was coming from. When we came together for the couples work, I said to both partners, "One of the most important things for this relationship is to understand where each of you is coming from at an emotional level-that is, the level at which you feel appreciated, admired and loved, or vulnerable, rejected and hurt. Let's take some time and share what each of you is experiencing at that level."

After a brief pause, Alicia started in.

Alicia: I guess I can go first. There are many times I don't feel that Frank cares about me or respects me. I ask him to respect my office space, but he comes in and leaves it a mess. I ask him to let me know when he is coming home, but he forgets to call. He knows I like hearing he loves me, but he rarely says that. Early in our relationship I felt he wanted to hold and protect me, and that he wanted to honor me. There were times that he could even be vulnerable with me. But now-now I just feel this coldness from him. And when I ask him to do things, like tell me when he is coming home, he just lashes out at me.

Me: Thank you, Alicia. You made clear some of the ways you used to feel valued and how that filled a need in you. And you noted that it has drifted and there are several times you experience Frank as being withholding or devaluing you in some way. Frank, I know from our earlier conversation, you also have lots of feelings about this relationship... (I indicate the floor is his.)

Frank: Well, you know, the relationship was better earlier. And now, not so much. She says I don't call, but I usually do. And I do tell her I love her...sometimes. (Frank stops there, despite my nonverbal cues to go on.)

Me: And, Frank, if you look deep inside, how do you feel about how she treats you? What do you feel about her and when does it feel better or worse?

Frank: It's okay, I guess. I mean, I don't know. The relationship-sometimes she annoys me. And sometimes I yell. But that doesn't happen all the time. The relationship is OK. Not great, but OK.

I glance over at Alicia, who is shaking her head in frustration. To speed the process along, I engage in a technique I call "directive empathy." Directive empathy uses the skills of the clinician to guide the empathetic understanding of the individual's inner experience and quickly conceptualize the situation. In this case, directive empathy was applied to the couple. It is crucial that this be artfully done. Because I had chatted with Frank, I knew where he was coming from. Although he was initially guarded, I was able to strike a good relationship with him fairly quickly, which allowed me to say things directly in a way that, if not done right, could have been very threatening.

Me: Let's take note of the differences in Alicia's response and Frank's. Frank, you had a much more difficult time talking about how you feel than Alicia did, didn't you?

Frank (nodding): I don't talk much about my feelings. People say I am cold, that I don't have feelings.

Me: I think you have feelings, Frank. In fact, my gut tells me you feel things very deeply. However, you don't know how to put your feelings into words. You have been socialized to be a "man," which to you means that you are independent and strong, that you don't need anyone else, and are not vulnerable. It means that if you get a feeling that you were criticized or rejected, a feeling that you were hurt, you can't stay there. Instead, you either get angry or withdraw or tell yourself you can handle it and it isn't even that big of a deal. That is why, even though there are rich feelings in there, you can't really talk about them, not even privately to yourself. And it is especially difficult to share them publicly and tell Alicia. Does that sound close to your experience, Frank?

Frank: Yeah, I guess that sounds about right. It is hard for me to say stuff like that.

Me: Yes. And that difficulty is creating a lot of static in your relationship with Alicia. How about, Frank, if I try to tell Alicia what you are feeling, as I sense it. I will model it for you. And it will also give Alicia a chance to hear a more detailed articulation of what is going on inside. And if I am off, then you can let me know. Is that cool with you?

Frank: Yes, you can tell her.

Me: Alicia, there have been many times over the last several years that Frank has felt that you don't respect him as a man or a husband. When he makes dinner for you and you don't thank him. Or when he built the entertainment center and you said it looked "big," rather than recognizing the craftsmanship that went into it, that hurt. When he asks, "Why are you already in bed under the covers?" he is saying that he wants to be with you physically and when you tell him you are tired and ready for sleep he feels rejected. When you noted that he was not bringing in as much money as he used to and that now you were making more than he, he felt that he lost some worth in the relationship. When you pointed out that he was going grey and balding, he felt you did not desire him. Frank does not know how to tell you these things. Indeed, he does not know how to really feel them himself. Instead, when he feels initially hurt or vulnerable, he then feels anxious and uncertain. And when he feels that way, he quickly justifies why he is his own man, and if it is not good enough for you, then screw you, he will just withdraw to himself. Frank, does that sound about right?

Frank: Yeah. That about covers it.

Me (to Alicia): How was that to hear?

Alicia (with tears welling up inside): I wondered if he felt anything. I felt like he just did not care. Or if he felt anything, it was just annoyed being with me because I was not good enough. A part of me sensed what you are saying, but he never says anything, so I just assumed he did not care.

Me: He cared alright. It is just that he was defended against putting his vulnerability out there, even to himself.

Frank's difficulty articulating his inner feelings, especially feelings like hurt or vulnerability-or needs to be held, sexually desired, or admired-is an example of what Levant characterized as normative male alexithymia.

Alexithymia is the clinical-sounding term for when someone has a lot of difficulty translating their emotional experience into words. Normative male** alexithymia refers to the fact that traditional masculine role socialization channels many men into ways of being such that their masculine identity conflicts with many emotions they feel and what they feel they are "allowed" to express (i.e., they will be shamed and will feel as if they are "not real men" if they express feelings of vulnerability, dependency needs, weakness, etc.).

This can create enormous difficulty in relationships because the key variable in guiding couples to come together-or driving them apart, if the need is not met-is each partner's need to feel known and valued by the other. If either partner cannot put into words their feelings about not being known and valued, but instead hides, defends, or deflects such feelings, then the chances of disharmony and vicious relational cycles are greatly increased.
* As is always the case when writing about clinical encounters on my blog, all names and identifying information and details are changed. The above description represents an amalgamation of themes seen over many years in the clinic room. ** While it is often the case that males experience more difficulty with this (especially traditionally masculine men), it is of course also the case that many women can experience problems with this issue-and that many men are quite competent in sharing their core feelings.

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Why Is It So Hard for Some Men to Share Their Feelings?

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A recent clinical encounter reminded me of an important point about the way many modern men experience their emotions and needs, and how this can have a dramatic impact on relationship quality and lead to all sorts of confusion and conflict.

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When you first enter therapy, it might be surprisingly difficult to answer the question, "How are you feeling?" Answering that question can be even more of a challenge if you deal with what is known as alexithymia, a dysfunction that makes it tough to recognize and name your emotions.

Many people who have depression, post-traumatic stress disorder (PTSD), or other mental health conditions also deal with alexithymia-and it's also a more common issue than many people realize. For instance, Alyson Stoner, who is known for her roles in Cheaper By the Dozen and Camp Rock, recently told People that she had severe anxiety when she was six and eventually developed eating disorders, as well as alexithymia.

If you've never heard of alexithymia before, you're not the only one.

Although alexithymia is well known among psychologists, it's not something most people outside the field are aware of. And even though mental health professionals have known of the existence of this condition for years, it's still a little bit of a mystery, John Richey, Ph.D., an associate professor of psychology at Virginia Tech who has researched alexithymia, tells SELF.

Alexithymia is essentially a dysfunction in the normal emotional awareness processes that makes it tough for people to put a label on their feelings, Richey explains. In research, it has been described as a "personality construct characterized by altered emotional awareness" and something that " negatively impacts empathic processing." In practice, alexithymia makes it difficult to recognize when you're feeling something and even more difficult to assign a name to it.

"We're constantly applying labels to complicated internal states like happiness and sadness, and that takes practice over time," Richey says. "For some people, for reasons that are not clear, they have difficulty decoding what's going on inside their own internal world and giving it a name."

That said, alexithymia isn't actually a condition, and it's not in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the diagnostic handbook used by health care professionals to diagnose mental disorders, Kathryn Moore, Ph.D., psychologist at Providence Saint John's Child and Family Development Center in Santa Monica, California, tells SELF. "It's usually an aspect of a person's functioning and how they deal with emotions, but it's not a separate diagnosis," she says.

Alexithymia has been linked to a range of mental health disorders like depression, PTSD, schizophrenia, and autism spectrum disorder. It's also associated with suicide, elevated mortality rates, and psychosomatic issues (e.g. a physical illness caused by mental conflict or stress).

It also seems to be more common in men than women, and people can experience alexithymia to varying degrees, Sophie Lazarus, Ph.D., a psychologist at the Ohio State University Wexner Medical Center, tells SELF. "People vary widely in the degree to which they are in touch with and able to describe their own emotions," she says. "This likely depends on a number of factors, including how much this was modeled, reinforced, or punished in their early environment."

A person might not be aware they have alexithymia.

Considering that alexithymia is characterized by a lack of awareness or recognition of an internal state, it's probably not surprising that "people usually aren't fully aware that they have this difficulty," Richey says. That's also why many people don't seek treatment for it, which makes it difficult to know exactly how common it is on its own rather than when it occurs with a disorder, such as depression.

Even if someone is diagnosed with alexithymia, it can be difficult to treat. "There's so little research on whether you can even get rid of it," Richey says. But how you developed alexithymia likely matters in whether it's treatable, he says. If you're experiencing it as a result of depression or PTSD, for example, it's likely that therapy (as well as treating the other mental health issues you're struggling with) can help. But for others, alexithymia could just be "more an enduring trait over time," Richey says.

For people who experience alexithymia, it may be helpful to:

Learn to connect your emotions with the physical feelings that can come with them, like an accelerated heartbeat, sweating, or sluggishness, Richey says.

Try cognitive behavioral therapy (CBT) to focus on identifying and understanding the connection between thoughts and emotions, Lazarus says.

Practice mindfulness and other exercises to increase your emotional awareness, Lazarus says.

Enter group therapy programs, Moore suggests, which will give you the opportunity to see how others talk about their emotions.

Reflect on your personal beliefs about emotion and what you think will happen if you display your emotions, Moore says.

Still, although therapy is generally recommended (and may be a given if you're already treating another mental health issue), it's not guaranteed to work for everyone. "Some people do well with starting to apply names and labels to emotions in the context of therapy, while others struggle with it profoundly," Richey says. "It's very specific to the person and the context."

Overall, more research is needed to better understand alexithymia and how to treat it effectively. "As a field, we still don't have a good understanding of why or how this happens in some people," Richey says. "But we're learning a little more each year."
Related:

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When you first enter therapy, it might be surprisingly difficult to answer the question, "How are you feeling?" Answering that question can be even more of a challenge if you deal with what is known as alexithymia, a dysfunction that makes it tough to recognize and name your emotions.

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Allan Schwartz, LCSW, Ph.D. was in private practice for more than thirty years. He is a Licensed Clinical Social Worker in the states...Read More
"She was a thirty year old married woman who had lost her job for no reason she could understand. In fact, while still working other people shunned her, never inviting her to lunch or other social events connected with the office. She never understood the reasons for this but was aware of feeling lonely. She did want to belong. Things at home were much the same. She had a loveless and sexless marriage primarily because she had no interest in sex. In therapy she seemed flat, uninterested, silent and spoke in a way that was monotonous. She reported having nothing to talk about and nothing to say. Ultimately, the therapist started to engage her in casual conversation about very mundane and concrete things. For example, how was her dog, did she walk him today, did she speak to her mother, did she see her younger sister? The question about walking her dog stemmed from the fact that she avoided leaving the house as much as possible. She did not want to see people and felt very uncomfortable around them. She was depressed and was able to acknowledge that fact but only if asked."
This patient was a good example of someone with Alexithymia.

What is Alexithymia?

Alexithymia is a personality characteristic in which the individual is unable to identify and describe their emotions. The main feature of Alexithymia is an emotional unawareness, lack of social attachment, and poor interpersonal relating. Furthermore, those suffering from Alexithymia have difficulty recognizing and understanding the emotions of others.

Alexithymia means there is:

1.Difficulty identifying feelings and distinguishing between feelings and the bodily sensations.

2.Difficulty describing feelings to other people.

3.Limited imagination and, therefore, little or no fantasies and limited dreams.

4.An unawareness of what is happening in their own mind and a very concrete way of thinking.

To illustrate these types of problems, this patient would occasionally report dreams but have no interest in them other than that. In a way, she illustrated the saying that, "a cigar is just a cigar," which was what was said of Freud's interpretation of the meaning of dreams. To her, there was no meaning to her dreams. In another example, I suggested she do I role play in which she imagine she was speaking to her father in an empty chair next to her. The idea was that she have the opportunity to tell him more about herself. She thought the entire idea was ridiculous and would not give it any more thought. She also had many somatic problems. At one time it was thought that she have Fibromyalgia because of all of her complaints about being in pain and of being chronically tired. Chronic Fatigue Syndrome was under consideration but that would not account for her pains. All of her medical tests were negative. Asked if she thought there might be a connection between her depression, social isolation, and lack of sex that could cause her to feel ill, she rejected the question as being ridiculous. Her body was shouting at her but she could not hear the message.

Ultimately, her husband left her and sued for divorce. She was completely shocked. Yet, she could never grasp the notion that her husband could be sexually frustrated. She seemingly had no understanding of him at all. In point of fact there were many things that frustrated him. In addition to the lack of sex there was the inability to go out to dinner, the movies, have friends over the house for entertainment or do any of the things couples do to enjoy married life. In coping with losing him she had no insight into any of these things.

There are some suggestions that Alexithymia is connected to the Autism. It's an interesting theory because her father fell on the autism spectrum. Coming to many of the family sessions that were conducted, he was unable to maintain eye contact. He was a successful man whose career had been in physics and engineering. He described his ability to concentrate on his work in college. He was able to focus his mind completely on his studying and block out any noise around him. He did the same during his examinations, being free of distractions of other students, noises, movements or the environment. Unfortunately, this ability to focus did not help him in raising his daughter. He was an absentee father, always at work and away from the family. However, his success was probably due to the fact that, on the autism spectrum, he suffered with Asperger's Disorder. Socially, he did not function well but his keen intellect and brilliant understandings of the most difficult concepts in physics made him an invaluable member of any engineering team.

This patient began to make slow progress after she was referred to an intensive program that set about teaching her how to relate socially and how to think about her physical sensations and how they are different from her emotions.

Those with Alexithymia have a sad and lonely existence. It is as though, in a world of multiple and beautiful colors, they can only see black and while. As psychiatry begins to make progress on learning about and treating this disorder, new treatment methods are being developed to help these people.

While they are able to marry, most end up in divorce situations because of their inability to interact with their partner.

Do you know someone who might have Alexithymia?Does this sound familiar? Help them reach out for help.

Your questions and comments are encouraged.

Allan N. Schwartz, PhD

Keep Reading By Author Allan Schwartz, LCSW, Ph.D.

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Allan Schwartz, LCSW, Ph.D. was in private practice for more than thirty years. He is a Licensed Clinical Social Worker in the states ...Read More "She was a thirty year old married woman who had lost her job for no reason she could understand.

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Virtually everyone has experienced from time to time how hard it can be to put one's feelings into words. Yet, for some individuals, this task is especially daunting. Such individuals are characterized by high levels of alexithymia ("no words for feelings"). Alexithymia is a personality dimension that involves both cognitive deficits, including difficulties in recognizing, describing, and distinguishing feelings from bodily sensations of emotional arousal, and affective deficits, including difficulties in emotionalizing and fantasizing (Bermond et al., 2007). Alexithymia is implicated in a wide variety of psychological problems, such as depression (Honkalampi et al., 2000) and schizophrenia (Rotenberg, 1994). Moreover, emotional deficits in autism spectrum disorder may be largely driven by alexithymia (Bird and Cook, 2013). Finally, alexithymia is associated with suicidality (Hintikka et al., 2004), increased psychosomatic complaints (Lane, 2008) and elevated mortality rates (Tolmunen et al., 2010).

Since the term "alexithymia" was introduced some four decades ago by Sifneos ( 1973), individual differences in alexithymia have been the focus of considerable research efforts. Indeed, at the time of writing this article (October 14, 2013), we counted more than 1400 articles in the PsychInfo database with "alexithymia" in the title or abstract. This research has analyzed many different facets of alexithymia, including its behavioral, linguistic, physiological, and neurological correlates (for recent reviews, see Taylor and Bagby, 2004; Kano and Fukudo, 2013; Nowakowski et al., 2013; van der Velde et al., 2013) as well as its assessment techniques (for a review, see Lumley et al., 2007). The accumulated knowledge based on the formation and assessment provides valuable insights into alexithymia. Nevertheless, researchers have so far taken few steps to translate these insights into treatments and interventions.

The current lack of translational work in alexithymia research seems highly unfortunate, considering that epidemiological studies indicate that as many as 10% of the general population may be characterized by levels of alexithymia that are sufficiently high to qualify as pathological (Salminen et al., 1999). Basic research remains necessary to answer unresolved questions about alexithymia. Nevertheless, a number of empirical findings on alexithymia now seem sufficiently well-established to consider their clinical application. Ogrodniczuk et al. ( 2011) found that high-alexithymic individuals seeking a treatment are as open as low-alexithymic individuals to receiving psychotherapy. Moreover, several studies have shown that alexithymia scores may decline during psychotherapy and such changes are correlated with improvement in therapy. For instance, high-alexithymic individuals may benefit from cognitive behavioral therapy (Spek et al., 2008) and also seem responsive to group therapy (e.g., Beresnevaite, 2000; Ogrodniczuk et al., 2011). As Ogrodniczuk et al., concluded, "This implies that alexithymic patients can at least partly develop some capacity to recognize their feelings and to communicate them to other people, thus enhancing their ability to use emotional information to guide adaptive behavior."

Nevertheless, to the best of our knowledge, there exists no treatment specifically designed to overcome the problems associated with alexithymia. Furthermore, many existing forms of psychotherapy may be less than optimal for helping high-alexithymic individuals, given that they typically achieve poorer outcomes in psychotherapy than low-alexithymic individuals (Bach and Bach, 1995; McCallum et al., 2003; Ogrodniczuk et al., 2011). It therefore seems prudent to develop treatments that are specifically designed to overcome the problems associated with alexithymia. Offering such treatments to high-alexithymic individuals may significantly boost the effectiveness of psychotherapy within this group.

We therefore call upon researchers to consider more systematically how basic research findings may be translated into tools for improving the fate of alexithymic individuals. To facilitate the translation process, we briefly describe some promising ways in which alexithymia research may be converted into clinical interventions. Notably, our discussion is selective rather than exhaustive. We aim to identify the "low hanging fruit" that can be profitably explored by researchers who are interested in developing more effective evidence-based treatments for alexithymia.

Alexithymia and emotion processing

Deficits in emotional processing are central to the notion of alexithymia. Indeed, behavioral experiments have shown that alexithymia is linked to poorer recognition of emotional expressions in faces (Grynberg et al., 2012; Cook et al., 2013) and lower recall for emotional material (Luminet et al., 2006). One straightforward clinical use of these tasks may lie in helping practitioners to refine their diagnosis of alexithymia. To this end, it will be important to develop standardized emotion processing tasks that have norm scores for appropriate populations.

Beyond diagnosis, however, an exciting possibility is that emotional processing tasks may be used to train emotional skills among alexithymic individuals. Here, an analogy may be drawn with research on attentional biases in individuals with anxiety disorders (see Mathews and MacLeod, 2002). Initial research showed that high-anxious individuals display an attentional bias toward threatening stimuli. The same tasks that were used to demonstrate this attentional bias were subsequently modified by researchers to train high-anxious individuals to shift their attention away from threatening stimuli. In an analogous manner, experimental tasks that have so far been used to demonstrate deficient emotion processes among alexithymic individuals may be modified to overcome these deficiencies. For instance, alexithymic individuals may be trained to better recognize emotional expressions in faces (see Cook et al., 2013, for a relevant task) and to have better recollection of emotional memories (see Luminet et al., 2006). Examining whether such training tasks may benefit alexithymic individuals seems a worthy question for future research.

Alexithymia and language

Among human beings, the ability to express emotions requires processing at the linguistic level. Thus, linguistic processing plays a key role in alexithymia. Indeed, alexithymic people display impaired processing of emotional language at multiple levels. At a basic perceptual level, alexithymic people display poorer sensitivity to the emotional meanings of language. For instance, relative to low-alexithymic individuals, high-alexithymic individuals showed less facilitation from priming emotional contexts on the processing of emotion words (Suslow and Junghanns, 2002). Alexithymic people are further impaired in the perception and processing of speech prosody, or melody of speech, with emotional content (Goerlich et al., 2013). One possible linguistic intervention might consist of training alexithymic individuals in affect labeling that is, in lexicalizing emotional aspects of emotional stimuli and events. Research among general populations (which did not assess alexithymia) indicates that affect labeling improves emotion regulation (Lieberman et al., 2011). Thus, affect labeling could be an effective antidote against alexithymia.

At a communicative level, alexithymic individuals further demonstrate problems in emotional language production and comprehension. In particular, alexithymic individuals display a limited ability to talk about interpersonal relationships (Meganck et al., 2009), describe others' emotional experiences (Bydlowski et al., 2005), and understand the emotions of others (Moriguchi et al., 2006; Swart et al., 2009). In personal narratives, alexithymic individuals tend to use vocabulary of limited complexity and their emotional discourse lacks any vivid descriptions (Meganck et al., 2009). Alexithymia is also linked to concretist thinking and avoidance of metaphors (Kreitler, 2002).

The impoverished linguistic style of alexithymic individuals may be enriched by training them to use metaphors (Kousta et al., 2011) and mental imagery (Holmes and Mathews, 2010). A recent series of innovative experiments by Kidd and Castano ( 2013) suggests that reading literary fiction (as opposed to non-literary texts) can improve people's ability to identify and understand other's subjective states. These are among the primary social-cognitive abilities that are impaired among alexithymic individuals. As such, the intriguing possibility arises that alexithymic individuals may overcome some of their communicative difficulties by reading works of literary fiction, and perhaps also by receiving appropriate training in literary skills (e.g., poetry or creative writing).

Oxytocin and neurofeedback

Recent years have seen a rapid growth of physiological and neuroscientific studies of alexithymia. Even though research within these areas is relatively novel, some of this research shows some promising therapeutic potential.

The neuropeptide oxytocin has been found to alter the perceptual salience and/or processing of social cues and to increase socio-emotional communication and trust (Carter, 1998; Bartz et al., 2011). Although oxytocin is naturally produced by the body, it can also be externally administered by inhaling it through the nose. Administration studies indicate that oxytocin fosters social-cognitive processes that are impaired among alexithymic individuals. For instance, a recent study showed that intranasal oxytocin increases people's willingness to verbally share painful emotions (Lane et al., 2013). Importantly, oxytocin did not simply make people more talkative but instead specifically increased the willingness to share emotions. Preclinical and clinical studies have identified important links between oxytocin and a range of psychiatric disorders, and have now started to directly assess its therapeutic potential in treating socio-emotional functioning deficits (Matsuzaki et al., 2012; Macdonald and Feifel, 2013; Tops et al., 2013). Most relevant here, a recent study suggests that the social-cognitive benefits of oxytocin are particularly pronounced among individuals who score high (rather than low) on alexithymia (Luminet et al., 2011). Oxytocin may impact on central aspects of alexithymia such as the decreased recognition, expression, and consequently sharing of emotions. Although more research is clearly needed, these preliminary findings suggest that intranasal oxytocin might have therapeutic benefits, perhaps as an adjunct to therapy or training.

Neuroimaging research has further linked alexithymia to decreased neural activations to emotional stimuli [see van der Velde et al. ( 2013), for a meta-analysis]. Interventions might target these specific neural areas using specialized techniques. For instance, online transcranial magnetic stimulation can be used to activate brain areas that are involved in emotion as well as language [e.g., the inferior frontal gyrus (IFG); Hartwigsen et al., 2010; Hoekert et al., 2010]. Moreover, brain areas (e.g., the anterior insula) that have been implicated in empathy, emotion, interoceptive awareness, and alexithymia (e.g., Bird et al., 2010; Bernhardt et al., 2013) and areas involved in emotion and language (IFG; Rota et al., 2009) can be trained by neurofeedback using real-time functional magnetic resonance imaging (e.g., Caria et al., 2010). Alternatively, neurofeedback may be provided through low-cost technology such as near-infrared spectroscopy (Mihara et al., 2012), which can detect relevant functional activation in areas such as the IFG (Takei et al., 2013). Training of anterior insula activation also changes the appraisal of emotional stimuli (Caria et al., 2010) and in patients with schizophrenia it led to changes in the perception of emotions and modulations of the brain network connectivity (Ruiz et al., 2013). These findings open the door to further studies in alexithymia and psychiatric populations, and possible therapeutic applications.

Conclusions and outlook

The pains of putting one's feelings into words are a universal human experience that lies at heart of the personality dimension of alexithymia. Over the last four decades, the alexithymia construct has inspired volumes of research. The resulting wealth of empirical findings has illuminated many aspects of alexithymia, but so far has not resulted in the development of new, evidence-based treatments for improving the life of alexithymic individuals. Nevertheless, as we have outlined in this article, behavioral, linguistic, and neuroscience research on alexithymia seem to have progressed to a point where they may be translated into effective treatments for alexithymic individuals. These treatments may be delivered in innovative formats, such as Internet-based programs. These programs might be especially appealing to alexithymic individuals, because online communication provides a way to keep interpersonal contact at a minimum, lowering the need for openly sharing one's emotions. Treatments for alexithymia may be offered to complement existing clinical treatments, to permit high alexithymic individuals to derive more benefits from psychotherapy.

With this outline, we hope to stimulate researchers to invest more in the development of evidence-based treatments for alexithymia, and to evaluate these treatments in terms of their effectiveness. The findings of evaluative research may in turn inform basic research, creating a dynamic dialogue between practitioners and basic researchers. After four decades of basic research on alexithymia, the time seems ripe to move toward clinical applications.

Acknowledgments

This research was supported by a Veni grant of the Netherlands Organization for Scientific Research (NWO) (451-07-013) awarded to Mattie Tops and a Consolidator Grant of the European Research Council (ERC-2011-StG_20101124) awarded to Sander L. Koole.

References

Bernhardt B. C., Valk S. L., Silani G., Bird G., Frith U., Singer T. (2013). Selective disruption of sociocognitive structural brain networks in autism and alexithymia. Cereb. Cortex. [Epub ahead of print]. 10.1093/cercor/bht182 [[PubMed] [CrossRef] Google Scholar]

Goerlich K. S., Witteman J., Schiller N. O., van Heuven V. J., Aleman A., Martens S. (2013). Blunted feelings: alexithymia is associated with a diminished neural response to speech prosody. Soc. Cogn. Affect. Neurosci. [Epub ahead of print]. 10.1093/scan/nst075 [[PubMed] [PMC free article] [CrossRef] Google Scholar]

Macdonald K., Feifel D. (2013). Helping oxytocin deliver: considerations in the development of oxytocin-based therapeutics for brain disorders. Front. Neurosci. 7:35 10.3389/fnins.2013.00035 [[PubMed] [CrossRef] PMC free article] [Google Scholar]

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Four decades of research on alexithymia: moving toward clinical applications

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Virtually everyone has experienced from time to time how hard it can be to put one's feelings into words. Yet, for some individuals, this task is especially daunting. Such individuals are characterized by high levels of alexithymia ("no words for feelings").

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Alexithymia is an emotion-processing condition that leads to difficulties recognizing or reacting to emotions both in oneself and others, but symptoms of alexithymia are not as pronounced as emotional difficulties associated with conditions such as autism.

What is Alexithymia?

People with alexithymia often have other mental health conditions or developmental delays, particularly autism-spectrum diagnoses. The defining characteristic of alexithymia is difficulty in naming, noticing, or reacting to emotions. This can lead to problems with empathy, and many people with alexithymia struggle in relationships with spouses, friends, and family. People with alexithymia are especially likely to struggle with conflict resolution and avoidance because of their difficulties in recognizing the effects their words and deeds have on others.

Symptoms of alexithymia include:

The inability to verbalize one's own emotions or the emotions of others

Limited fantasy life and, among children, little pretend play

Difficulty reacting appropriately to other people's emotions

Struggling with empathy

Causes of Alexithymia

Researchers are not sure what causes alexithymia. It is likely that both genetic and environmental factors contribute to alexithymia. Children whose parents have alexithymia are more likely to have it themselves, and children who do not regularly interact with others or learn about feelings may later struggle with alexithymia.

Treatment for Alexithymia

Because alexithymia often co-occurs with other mental health conditions, treatment such as therapy, social skills training, and lifestyle changes that address those conditions can sometimes help the alexithymia as well. People who learn to recognize, describe, and react to emotions may greatly lessen symptoms of alexithymia and experience fewer problems with interpersonal relationships.
References:

1. Fitzgerald, M. (2004). Overlap Between Alexithymia and Asperger's Syndrome. American Journal of Psychiatry, 161(11), 2134-2135. doi: 10.1176/appi.ajp.161.11.2134

2. Roedema, T. M., & Simons, R. F. (1999, November 30). Emotion-processing deficit in alexithymia. University of Delaware. Retrieved from http://rsimons.psych.udel.edu/tomrev.htm

Last Updated: 08-4-2015

# data[].attributes.attachment_link.description
Alexithymia is an emotion-processing condition that leads to difficulties recognizing or reacting to emotions both in oneself and others, but symptoms of alexithymia are not as pronounced as emotional difficulties associated with conditions such as autism. People with alexithymia often have other mental health conditions or developmental delays, particularly autism-spectrum diagnoses.