· Horney (1952) found that some psychoanalytic clients failed to progress in their therapy
· She identified two clusters of indicators one ‘psychological’ the other ‘behavioural’
· Psychological indicators
· A dearth of ‘inner experience’
· Poor emotional awareness
· Concreteness of thinking
· Behavioural indicators
· Behaviour is guided by rules and regulations
· Behaviour is guided by the others’ expectations.
· Many were subject to psychosomatic disorders.
· Many showed compulsive behaviours.
· Krystal (1982–1983) concluded that “alexithymia is possibly the most important single factor diminishing the success of psychoanalysis and psychoanalytic psycho- therapy” (p. 364)
· Distinguishing Somatoform and Psychosomatic Disorders
· Somatoform – characterized by symptoms that indicate a physical illness but that illness is medically unexplained (MUS).
· Conversion disorders – characterized by some loss of physical function (e.g. blindness or paralysis) with no known physical cause
· Psychosomatic – in which mental factors play a role in the development, progression and treatment of an illness
· Ulcers & helicobacter pylori infection (about 80% concurrence)
· Ulcers & Stress (4/5 infected with Helicobacter pylori do not develop ulcers)
· Nemiah and Sifneos (1970)
· Investigated clients with a variety of psychosomatic diseases and
· These clients had
· difficulty in describing their feelings,
· an impoverished fantasy1 life,
· a cognitive style that is externally oriented, literal, and excessively pragmatic
· Sifneos (1973) coined the term alexithymia (from the Greek, a = lack of, lexis = words, thymos = emotions)
· Economic Costs of MUS’s
· Deary, Scott & Wilson (1997)
· Despite a large general latent trait (negative affectivity) the best model was a two-factor model that emphasized that alexithymia could make a contribution to MUS variance beyond that made by negative affectivity.
· Burton et al (2012)
· Patients who had been repeatedly referred with MUS had higher mean inpatient (£3,539), outpatient (£778) and emergency department (£99) costs than those infrequently referred.
· The mean overall costs were similar to those of patients who had been repeatedly referred with medically explained symptoms (£4916 vs £4379).
· Konnopka et al (2012)
· Cost of illness studies examining MUS’s found mean annual health care costs ranging from $1,584 to $6,424.
· On average the cost the US health system is greater than for both depression and anxiety (taken together)
· Quality of Life
· Alexithymia has been associated with higher incidences of
· Eating Disorders
· anorexia (e.g. Cochrane et al., 1993; Schmidt, Jiwany, & Treasure, 1993)
· bulimia (e.g. Cochrane et al., 1993; de Groot, Rodin, & Olmstead, 1995)
· binge-eating disorder (e.g. Pinaquy et al., 2003).
· Problem Gambling (Lumley and Roby, 1995; Parker et al., 2005; Toneatto et al., 2009)
· Alcohol Abuse (e.g. Shishido,Gaher and Simons, 2013; Lyver et al, 2012)
· Drug Abuse (e.g. Guilbaud et al, 2002; Gandolphe, 2012)
· All of the above are associated with a poor quality of life.
Development of the Alexithymia Construct
· Nemiah, Freyberger, and Sifneos (1976) expanded on their definition of alexithymia to include these following:
“(1) difficulty identifying feelings, differentiating among the range of common affects, and distinguishing between feelings and the bodily sensations of emotional arousal;
(2) difficulty finding words to describe feelings to other people;
(3) constricted imaginal processes, as evidenced by a paucity or absence of fantasies referable to drives and feelings; and
(4) a thought content characterized by a preoccupation with the minute details of external events (i.e., an externally oriented cognitive style)”
(Psychoanalysis and Empirical Research : The Example of Alexithymia
Taylor and Bagby, pg 103, 2013)
Features of the prototypic alexithymic person
Measurement of Alexithymia
· Self-report 20-item Toronto Alexithymia Scale (TAS-20; Bagby, Parker, and Taylor 1994; Bagby, Taylor, and Parker 1994; Parker, Taylor, and Bagby 2003),
· difficulty identifying feelings (DIF)
· difficulty describing feelings to others (DDF)
· externally oriented thinking (EOT)
· Translated into more than twenty languages
· three-factor structure cross-validated by confirmatory factor analysis in Western, Eastern European, East Asian, and Middle Eastern countries
· Self-report 40-item Bermond-Vorst Alexithymia Questionnaire (BVAQ; Borst and Vermond, 2001)
· Five subscales
· Emotionalizing, Fantasizing, Identifying, Analyzing, and Verbalizing
· Belgium and Dutch Samples
Alexithymia is a personality variable and NOT a clinical diagnosis
· Taxonometric Studies
· Parker et al (2008)
· large community (1,933) and undergraduate (1,948) samples and in a smaller sample of psychiatric outpatients (302).
· No evidence of a separate category (taxon)
· Mattila et al (2010)
· 5194 (2377 men, 2817 women) residents of Finland
· No evidence of a separate category (taxon)
· Multiple Types
· Bermond (1997) proposed two types of alexithymia:
· Type I – by low degree of conscious awareness of emotional arousal and a low degree of emotion accompanying cognitions;
· Type II - normal or high degree of conscious awareness of emotional arousal together with a low degree of emotion accompanying cognitions
· Bagby et al (2009) using confirmatory factor analysis failed to find evidence of two types.
Alexithymia & Affect
· Nemiah, Freyberger, and Sifneos (1976)
· Emotion - the neurophysiological and somatic component of affect
· Feelings – the subjective, cognitive-experiential component of affect
· Damasio (2003),
· “emotions play out in the theater of the body. Feelings play out in the theater of the mind” (p. 28)
· Sifneos (1994) and Taylor, Bagby, and Parker (1997) proposed that alexithymia reflects a deficit in the cognitive processing of emotions which leads to
· focusing on, and amplification of, the somatic sensations accompanying emotional arousal
· regulating tension through compulsive behaviors such as smoking, binge eating, and abuse of alcohol or drugs
Alexithymia & Genetics
· There is a correlation between mothers’ and fathers’ alexithymia scores with their children’s alexithymia scores (Lumley et al, 1996; Fukunishi & Paris, 2001; Grabe et al, 2008)
· Genetic factors significantly contribute to variation in brain structures (Schmitt et al, 2007; Peper et al, 2007)
· Several twin studies have shown a link between alexithymia and heritability (Heiberg and Heiberg, 1978; Valera and Berenbaum, 2001; Jorgensen et al, 2007; Picardi et al, 2011)
Picardi et al (2011)
· A total of 2930 twins (aged 23-24 years) were contacted. The twins received the study assessment instruments in the mail.
· A total of 758 twins (25.9%) agreed to participate and returned the questionnaires.
· Zygosity was assigned by means of a standard questionnaire evaluating the degree of physical similarity of twins during infancy
· known to be 95% accurate in identifying mono- and di- zygotic twins
· Alexithymia was measured with the Italian version of the 20-item Toronto Alexithymia Scale (TAS-20)
· Depression was measured with the Positively-phrased Depression Scale (PDS)
· “Genetic factors accounted for 42% of individual differences in alexithymia. Unshared environmental factors explained the remaining proportion of variance. There was a substantial (0.65) genetic correlation between alexithymia and depression. The inclusion of depression as a covariate in the genetic models reduced the heritability estimate for alexithymia to 33%.” (Picardi et al, pg 256).
· Other genetic studies found heritability scores ranging from 30% to 43%
· Approximately 1/3rd of the variability in alexithymia can be accounted for by a combination of additive and non-additive genetic effects
· Approximately 2/3rds of the variability in alexithymia is accounted for by non-identified environmental effects
Alexithymia and Attachment.
· A common explanation for the development of alexithymia is problems in the attachment process.
· Studies have shown that normal brain development requires relevant experience (e.g., Greenough, Black, & Wallace, 1987)
· Variations in experience can produce differences in brain structure (e.g., Black, Jones, Nelson, & Greenough, 1998; Kaffman & Meaney, 2007; Marshall & Kenney, 2009)
· Sroufe, Coffino and Carlson (2010) point out that:
· it is not always the case that early experience is most critical
· the consequences of earlier and later experience are cumulative
· the impact of early experience may at times be transformed by subsequent experience
· Bowlby’s (1969, 1973, 1980) translated ‘love’ into the more precise concept of attachment.
· He differentiated attachment and dependency
· He put an emphasis on the function of selective attachments in providing security
· He argued that early selective attachment was the forerunner of later social relationships.
· Attachment is typically a bond between an individual child and an attachment figure (usually a caregiver).
· These bonds are based on the child's need for safety, security and protection
· Bowlby suggested that children attach to carers instinctively for the purpose of survival.
Brennan, clark and shaver (1998)
Attachment and life span
· Goldberg (1991)
· attachment style developed in childhood remains relatively stable across the life span and may even be transmitted between generations.
· Waters et al (2000)
· 60 white middle class infants were seen in the Ainsworth Strange Situation at 12 months. 50 of these participants (21 males, 29 females) were interviewed using the Berkeley Adult Attachment Interview (AAI) 20 years later.
· 72% of the participants received the same secure versus insecure attachment classification in early adulthood.
· Negative life events (e.g. loss of parent, divorce of parents, life-threatening illness of parent or child, psychiatric disorder of the parent) were important factors in change of attachment classifications.
Attachment, Emotional Regulation and the Brain
· Hindy & Schwarz, 1994 (also, Rothbard & Shaver, 1994)
· people with secure attachment styles have low levels of negative affect.
· Parker (1982)
· Insecure styles of attachment
· less positive affect than those with secure attachments
· deficits in the ability to self-regulate anxiety, depression and other negative affects.
· Schore (1994, 2000, 2003, 2005) argued that attachment is related to right brain development.
· Bradshaw and Schore (2007)
· The brain’s major self-regulatory systems are located in the orbital prefrontal areas of the right hemisphere.
· They undergo an anatomical maturation in postnatal periods of mammalian development
Montebarocci et al (2002)
· In this study 301 University students completed the Attachment Style Questionnaire (ASQ) and the Toronto Alexithymia Scale
· For women and men the same pattern of correlation is observed
· Except “Preoccupation with Relationships” and the “Difficulty Communicating Feelings” was significant only in the male group.
Scheidt et al (1999) – The case of idiopathic spasmodic torticollis
· Twenty patients with IST and 20 healthy controls matched for age and sex were administered the Toronto Alexithymia Scale (TAS-20) and the Adult Attachment Interview (AAI).
· Attachment was classified using the Attachment Interview Q-sort. IST patients scored significantly higher on the measure of alexithymia than subjects in the comparison group.
Alexithymia and Childhood Trauma/Abuse
· Krystal (1978, 1988)
· Alexithymia is a consequence of “psychic trauma” experience by the infant before “affects are fully desomatized, differentiated and represented in language”
· Zlotnick, Mattia and Zimmerman (2001)
· a greater severity of emotional neglect and physical neglect, rather than abuse, was significantly related to higher levels of alexithymia
· Paivio and McCulloch (2004)
Alexithymia and the Brain
· Taylor, Bagby & Parker (1997) suggest two possible neurobiological explanations for alexithymia (based on a review of the literature)
· Right Hemisphere Dysfunction – generally associated with emotion processing
· Interhemispheric transfer deficits
· In a more recent review (Wingbermuhle et al, 2011) a number other brain structures may also be implicated in Alexithymia
· Corpus Callosum
· Amygdala - emotional processing, motivation and emotional memory
· Anterior Cingulate Cortex - ‘executive’ functions and goal-directed behaviour
· Posterior Cingulate Cortex – ‘evaluative’ function with respect to emotions
· Anterior Insular Cortex - mapping internal body states and integrating them in conscious representations of ‘feeling’ states
· Pre-Frontal Cortex - higher cognitive/emotional functions, e.g., decision-making, planning, moderating appropriate social behaviour and impulse control
· All these regions are commonly assumed to be involved in the processing of emotions
Kano et al (2003)
· An imaging study using positron emission tomography (PET) analysed regional cerebral blood flow (rCBF) in 12 alexithymic and 12 non-alexithymic participants.
· Participants viewed (A) angry, (B) sad, (C) happy and (D) neutral faces .
· Alexithymics showed lower rCBF in the right hemisphere.
· Alexithymics showed higher rCBF in the left hemisphere.
· Hoppe and Bogen (1977)
· Studied 12 patients before and after split- brain surgery
· All were highly alexithymic post surgery
· There was a decrease in their ability to fantasize, to symbolise and to dream
· Ten Houten, Hoppe, Bogen and Walter (1986)
· 8 patients and 8 matched controls.
· Participants were shown a 3 minute film designed to evoke emotions (it involved death and loss)
· Split brain patients used fewer affect words to describe the film than matched controls.
Parker et al (1999)
· They used a tactile finger localization task
· Kugel et al (2008)
· Showed pictures of different emotional expressions to 21 student participants in a primed masking task
· They found a relatively strong correlation between TAS-20 scores and right amygdala activation
Anterior Cingulate Cortex (ACC)
· Lane et al (1998)
· Correlations between the ability to process emotional information and cerebral blood flow during film- and recall-induced emotion overlapped significantly (z = 3.74, p < 0.001) in Brodmann’s area 24 of the anterior cingulate cortex (ACC).
· Kano et al (2003, see earlier)
· Also showed an association between the ACC activation and alexithymia such that there was less activation for high alexithymia participants..
Berthoz et al (2002)
Posterior cingulate cortex
· Mantani et al (2005)
· “People with high degrees of alexithymia (HDA) are known to have constricted imaginal capacities. The purpose of this study was to investigate neural correlates of imagery disturbance in subjects with HDA”.
· Participants were instructed to imagine a past and future happy, sad and neutral events while undergoing a fMRI scan.
Anterior insular cortex
· Damasio (1994) suggested that the AIC maps internal bodily states, integrating them in conscious representations of feeling states.
· Kano et al. (2003)
· Alexithymic participants displayed decreased insular activity in response to angry faces.
· Kano et al (2007)
· The same research group found heightened activity in the right insula of TAS-20 alexithymics in response to visceral stimulation.
Pre frontal cortex
· Kano et al (2003).
· alexithymic subjects exhibited decreased activation in the inferior and superior frontal cortex and the orbital PFC of the right hemisphere, in reaction to negative emotional stimuli
· Mantani et al (2005).
· observed no differences between persons with and without alexithymia in activation of the orbital PFC.
· Moriguchi et al (2006)
· An fMRI study using ToM animations
· Alexithymics had lower mentalizing and scores and less activation in the right medial PFC
Alexithymia and the Brain
· The research suggests that many different brain regions are implicated in Alexithymia
· What all these regions have in common is that they are involved in the processing of Affect.
· Typically, the findings are of reduced activity in the those regions of the brain associated with emotion processing for individuals who are high in Alexithymia.
Prevalence of alexithymia
· Parker et al (2008)
· 10% in the normal population (though estimates vary between 4% and 17%)
· Shipko et al (1983)
· 41% of Vietnam War veterans with PTSD
· Cochrane et al (1993)
· 63% of patients with anorexia nervosa
· 56% of patients with bulimia
· Honkalampi et al (2001) and Kim et al (2008)
· 45% to 50% in major depressive disorder
· Cox et al (1995)
· 34% in panic disorder
· 28% in social phobics
· Taylor, Parker and Bagby (1990)
· 50% in substance abuse
· Lumley and Roby (1994)
· 41% of problem gamblers
Co-morbidities with alexithymia
· Williams and Wood (2010), Koponen, Taiminen, and Honkalampi (2005) and Becerra, Amos, and Jongenelis (2002)
· Co-occurs in individuals with acquired or traumatic brain injury
· Taylor, Bagby and Parker, (1997)
· Schizotypal, dependent and avoidant disorders
· Li and Sinha (2006) and Lumley et al (1994)
· Substance abuse
· Michetti et al (2006)
· Erectile dysfunction
· Jones (1984)
· Panic attacks
· Jula, Salminen, Saarijärvi (1999)
· Jones et al (2004)
· Functional dyspepsia
· Paivio and McCulloch (2002
· Self Harm
Treatment consequences of alexithymia
· Pretreatment alexithymia predicts prognosis of patients in medical, psychiatric, or behavioral treatments.
· poorer outcomes
· for anxiety and somatoform disorders (Bach & Bach, 1995),
· depression (Ogrodniczuk, Piper, & Joyce, 2004),
· alcoholism (Cleland, Magura, Foote, Rosenblum, & Kosanke, 2005; Loas, Fremaux, Otmani, Lecercle, & Delahousse, 1997),
· functional gastrointestinal disorders (Porcelli et al., 2003, 2004),
· mixed psychiatric disorders (McCallum, Piper, Ogrodniczuk, & Joyce, 2003).
· of group psychotherapy for complicated grief (Ogrodniczuk, Piper, & Joyce, 2005).
Treatment of alexithymia
· Patients who are unable to identify, differentiate, and articulate their emotions present psychotherapists with a difficult challenge (Taylor, 1984 and Kleinberg, 1996)
· Ogrodniczuka, Pipera, and Joyce (2011)
· Patients with high levels of alexithymia know that they do not feel good, but do not know how to say or describe what they are feeling.
· They have difficulty presenting material spontaneously and fixate on their physical symptoms and minute details of external events.
· Parker et al (1998)
· It has been shown to be associated with the use of “primitive and immature defences such as projection and denial”,
· Taylor et al (1997)
· Argue that alexithymia is associated with acting-out, dissociation, and passive–aggressive behaviour.
· Beresnevaite ́ (2000) randomized 37 post-heart-attack patients who had elevated TAS scores to either 4 months of weekly group therapy or two sessions of an educational control.
· Group therapy involved relaxation training, guidance in identifying and communicating feelings, imagery, music, and nonverbal emotional expression.
· Significant decreases in the TAS scores were found in the treatment group but not the control group, and
· decreases in TAS scores predicted better cardiovascular disease outcomes 2 years later.
· Ogrodniczuk et al (2009)
· Contrasted interpretive and supportive psychotherapy
· The interpretive therapist focused on exploring uncomfortable emotions, interpreting unconscious conflicts, using the transference as a therapeutic mechanism, and emphasizing the patient's role in the development and resolution of problems
· The supportive therapist focused on guiding the patient toward more adaptive modes of behaviour by using guidance, advice, and problem solving, directed blame for the patient's problems on external circumstances, and did not emphasize affect exploration
· Outcome measures were general symptoms, social–sexual maladjustment, and personalized target objectives.
· Alexithymia was measured using the TAS-20
· Difficulty identifying feelings was related to less improvement in general symptoms and social–sexual functioning.
· Externally oriented thinking was also associated with less improvement in social–sexual functioning.
· In supportive therapy, difficulty communicating feelings was associated with less improvement in general symptoms
· Taylor and Bagby (2013)
· “And consistent with clinicians’ reports of experiencing feelings of dullness, boredom, and frustration when attempting to treat alexithymic patients, empirical investigations in the context of group therapy have found that higher levels of alexithymia evoke negative reactions in therapists, and that these reactions partly contribute to poor treatment outcome (Ogrodniczuk, Piper, and Joyce 2011)” (page 122).