“Alexithymia? I have never heard of it.” This is one of the most common responses our team members hear from patients, healthcare professionals, and mental health providers. To be honest I didn't know what it was until nearly two years ago, and I had been practicing as a mental health provider for years at that point. Though it is estimated to impact 13% of the population (Obrębska & Rohoza, 2021), alexithymia is frequently overlooked and misunderstood by many physical and mental health providers. Despite it being shown to adversely impact mental and physical health treatment outcomes.
The most common features of alexithymia include difficulty identifying feelings, differentiating emotions and bodily sensations, trouble describing feelings to other people, reduced ability to visualize/imagine, logical or rigid thinking style, difficulty understanding other perspectives, and challenges with understanding and describing the emotions of others (Zdankiewicz-Ścigała et al., 2021). The above description of alexithymia is what will be commonly found in a Google search. However, like most conditions it is much more nuanced and complex than what is typically discussed online.
Alexithymia is a product of nature and nurture. It is rooted in physiology, but symptoms can become more pronounced through environmental and experiential influences. Alexithymia is often linked with higher rates of introversion due to the inability of alexithymic individuals to articulate their emotions. Studies show that limited maternal attachment and physical/emotional abuse can increase the severity of alexithymia symptoms. Even without traumatic experiences, unhealthy attachment, or chaotic environments alexithymia on its own can be a predictor of poor emotion regulation as well as more acute symptoms of depression and anxiety (Sfeir et al., 2020).
A less discussed feature of alexithymia is its impact on an individual's awareness of physical sensationsor states. Specifically, difficulties with interoception. Interoception refers to different physical and emotional information that occurs within the body. An individual's awareness of interoceptive signals is called interoceptive awareness and one's ability to accurately detect bodily signals is considered interoceptive accuracy. Understanding of bodily cues is critical for creating a sense of self, expressed emotional ideas, and development of individual emotional states (Aaron & , 2016).
Some researchers contend that alexithymia, at its core, is a deficit in interoceptive awareness and not a mental illness. The deficit in awareness of internal physical states disrupts emotional processes such as the physical experience of emotion (Aaron & , 2016). Patients with alexithymia not only have difficulty identifying their own emotions but also confuse these states with non-emotional interoceptive states, such as hunger, tiredness, and excitement (Zdankiewicz-Ścigała et al., 2021). This confusion may explain why alexithymia is often missed in mental health settings or presents in medical settings as unexplained physical symptoms.
Alexithymia has shown to be a strong predictor of resistance to physical and mental health treatment. Patients with alexithymia are more likely to experience somatic (difficult to explain) conditions like gastrointestinal, dermatologic, chronic pain (fibromyalgia), and seizure disorders (Elboğa, 2020; Iyaret al., 2019; Singh, 2021; Zdankiewicz-Ścigała et al., 2021). Additionally, alexithymia can be an exasperating factor of suicidal behaviors, sleep paralysis, and dissociative experiences among patients impacted by co-occurring psychiatric conditions (Obrębska & Rohoza, 2021; Pinna et al., 2020; Reyno et al., 2020).
Alexithymia is regularly connected to physical health conditions like inflammatory bowel disease, recurrent severe asthma, and essential hypertension (Wielopolski et al., 2017). Increased focus on aspects of physiological arousal can raise patients perceived intensity of physical symptoms. This elevates patients' risk of harmful perceptions of their health outcomes or prognosis (Aaron & , 2016).
Patients experiencing multiple pain locations and unexplainable pain sensations demonstrated considerably higher symptoms of alexithymia compared to other populations (Iyar et al., 2019). One study observed that alexithymia preceding to breast cancer surgery was the most accurate predictor of patients developing chronic pain one-year post-surgery (Aaron & , 2016). While a 2017 study found a correlation with tinnitus severity and alexithymic deficits in emotion regulation (Wielopolski et al., 2017).
Deficits in interception among alexithymic patients can also mimic neurological disorders. Psychogenic non-epileptic seizures (PNES) are like epileptic seizures. However, PNES are not associated with neurological seizure activity. Instead, they are thought to be the result of psychological difficulties. Studies have shown PNES patients experience higher levels of alexithymia and more frequent self-reported seizure activity. It is suspected that alexithymic patients diminished capacity to verbalize emotions when dealing with distress leads to them manifesting physically in the form of seizure like symptoms (Poli et al., 2022).
Alexithymia is associated with several different mental health disorders. Notably depression, panic disorder, eating disorders, alcohol dependence, posttraumatic stress disorder, and personality disorders. However, it has been under-recognized and under-diagnosed in the United States for years. The lack of recognition presents challenges across various healthcare settings and for clinicians (Da Silva et al., 2018; Wielopolski et al., 2017). This is often seen in patients with chronic mental health conditions that seem to stay at baseline for years despite receiving multiple treatment interventions.
Over the years disassociation has been connected to conditions like PTSD or schizophrenia. New research is pointing to alexithymia as a primary influence on dissociative experiences especially among neurodiverse populations. The connection is believed to be the result in a disconnection between conscious aspects of self-experiences and perceptions at both the emotional and physical levels. This causes problems with integrating thoughts, feelings, and experiences into consciousness as well as memory which negatively impacts emotional awareness, regulating emotions, and introspective abilities (Reyno et al., 2020).
Many of the features found in personality disorders are tied to alexithymia. Neuroimaging has found that individuals with increased alexithymia show reduced activation in regions of the brain involved in empathic processing. While self-report studies regularly demonstrate that alexithymia is linked with diminished forms of empathy including perspective taking and empathic concern (Aaron & , 2016). Based on recent findings the lack of empathic characteristics among populations with antisocial/narcissistic personality disorders could be explained by the co-occurrence of alexithymia.
Alexithymia may also explain many symptoms found within borderline personality disorder (BPD). One study found that 71.3% of patients with BPD were alexithymic. Most of the BPD patients in the study demonstrated alexithymia symptoms. Particularly, difficulties identifying and communicating feelings. Additionally, the researchers discovered a significant relationship between alexithymia symptoms and BPD patients self-harming behavior frequency/intensity (Poli et al., 2022).
The presence of interceptive subgroups of alexithymia further limits the effectiveness of many traditional medical and mental health interventions. Specifically, populations with low interoceptive accuracy and heightened accuracy. Low accuracy limits awareness of physical sensations relates to emotional experiences, preventing the development of conscious individual emotional states. On the other hand, heightened interoceptive accuracy increases amplification of bodily sensations, distracting from their emotional significance. For instance, patients may interpret bodily cues associated emotional experience as signs of physical illness (Aaron & , 2016).
Interestingly, we have observed patients who have demonstrated the ability to experience both low and heightened interceptive accuracy simultaneously where they may be hypo-aware of some physical sensations (i.e., hunger or thirst) while being hyper-aware of others (i.e., heart rate or breathing). In some cases, experiencing hypo and hyper-awareness of sensations within the same limb.
Studies have shown that alexithymia is disproportionately found among neurodiverse populations. Specifically, among individuals with attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). Researchers have estimated that 50% of people with ASD and over 40% of people with ADHD have co-occurring alexithymia (Bloch et al., 2021; Kiraz et al., 2020). Neurodiversity is the primary focus of our practice and though the practice is small, our experience aligns with the above research.
Many adults with ADHD and ASD are often diagnosed with and treated for depression prior being diagnosed with a neurodiverse condition. We have found that prior to establishing care with BHCS, most of our patients have carried a depression diagnosis for years, along with years of ineffective treatments. On average our patients' meet criteria for mild depressive symptoms (based on PHQ-9 data) despite entering care with a major depressive disorder (MDD) diagnosis. Conversely, on average many our patients meet criteria for alexithymia (based on TAS-20 data). Many of our patients report that symptoms of alexithymia resonate with their experience more than symptoms of MDD
| Variable | M | SD | n | SEM | Min | Max | Skewness | Kurtosis |
|---|---|---|---|---|---|---|---|---|
| PHQ-9 | 8.91 | 5.77 | 290 | .34 | 0.00 | 27.00 | .66 | 0.10 |
| TAS-20 | 54.85 | 11.62 | 194 | 0.83 | 28.00 | 83.00 | 0.01 | -0.60 |
Current research on alexithymia is debunking many of the myths surrounding ASD. Specifically, traditionally held opinions on limited empathy traits within autistic populations. Studies have found that ASD populations with elevated levels of alexithymia are more likely to demonstrate empathic deficits. Many researchers now believe that diminished emotional symptoms of ASD are more likely caused by the high co-occurrence of alexithymia within this population and not due to autism (Aaron & , 2016).
Alexithymia has been commonly associated with increased marijuana use, caffeine consumption, mobile phone addiction, compulsive gambling, and more acute alexithymia symptoms are commonly linked with more intense methamphetamine cravings (Huang et al., 2022). While studies indicate cigarette and other nicotine consumption is associated with alexithymic behavior. Researchers found smoking is often a coping mechanism to manage unpleasant physical/emotional sensations caused by alexithymia (Sfeir et al., 2020).
Among populations with alcohol use disorders 30-67% report experiencing symptoms related with alexithymia. People with combined alexithymia and alcohol addiction show more interpersonal difficulties, increased alcohol dependence severity, and greater relapse rates. Since alexithymic symptoms prevent individuals from coping effectively with stressors, due to lack of emotional awareness, impaired capacity to identify stressful events, and the tendency to use action as a general response to addressing issues regularly lead to increased alcohol intake (Thorberg et al., 2019).
Alexithymia is a common co-occurrence in eating disorders like anorexia, bulimia, and binge-eating disorder. Alexithymic traits seem to be especially comorbid with patients with anorexia and it has been estimated that alexithymia symptoms are present in as many as 77% of female patients (Vuillier et al., 2020). Alexithymia may be a facilitator in the relationship between ADHD and binge eating. Individuals with eating disorders demonstrate many traits associated with alexithymia. Specifically, difficulty identifying and describing emotions compared to those without eating disorders (El Archi et al., 2021).
It is estimated that the relapse rate for substance use disorders between 40% and 60% (American Addiction Centers, 2022). The high prevalence of alexithymia in populations with addictions may explain the lack of long-term treatment outcomes. A large percentage of our patients with alexithymia have been through multiple inpatient and outpatient addictions treatment programs. After receiving an alexithymia diagnosis these patients reported that it was not assessed or even mentioned when they were being treated for their addiction concerns.
With alexithymia being rooted in physiology symptoms regularly manifest in early childhood. It has also been shown to develop in adolescence and adulthood. Many patients report that their ability to manage alexithymic symptoms decreases as they age, and studies show a general age-related decline in emotion recognition capabilities. Specifically, sensitivity to internal emotional experiences lessens during adult development (Reyno et al., 2020).
Alexithymia has been shown to exasperate negative behaviors in children. Studies have found higher levels of alexithymia among autistic children and adolescents. Some researchers believe that alexithymia may be a key contributing factor to autistic children's emotional and social difficulties (Vaiouli et al., 2022). Alexithymic behaviors are often correlated with immaturity of defense mechanisms which leads to alexithymic youth engaging in more episodes of physical and verbal aggression. One study found higher rates of physical/verbal aggression, anger, and hostility in teenagers with alexithymia (Sfeir et al., 2020).
The impact of alexithymia on relationships cannot be understated. Especially, among neurodiverse individuals who often feel misunderstood and invalidated during general interactions neurotypical populations. Studies exploring alexithymia indicated that alexithymia better explains the difficulties shown by autistic individuals in identifying the emotional aspects of verbal, auditory, and visual communication. It also impacts individuals with ASD in emotion regulation, interpersonal relationships, and identifying emotions (Vaiouli et al., 2022).
Alexithymia's neurological/physical deficits and complete lack of awareness of the condition causes relationship distress across multiple environments. Individuals with higher levels of alexithymia not only have a deficit in the cognitive processing of their emotions, but they also have a less complex and integrated sense of self and others. The lack of internal integration contributes to interpersonal troubles which decreases individual autonomy, environmental understanding, and self-acceptance over time. This may intensify the emotional processing deficits with a defensive mindset, further limiting relationship capacities with increasing age (Reyno et al., 2020).
Because of their difficulties in expressing their genuine emotions alexithymic patients frequently display higher levels of anger and more aggressive behaviors (Sfeir et al., 2020). This supports studies that show perpetrators of domestic violence have higher levels of alexithymia and ADHD (Romero-Martínez et al., 2020). Alexithymic patients with less severe presentation report that their inability to identify or communicate emotions have drastically impacted their relationships. Likewise, the lack of awareness of the emotional needs of significant others, children, friends, and coworkers frequently has negative consequences in their lives.
Many of our patients living with alexithymia experience a lot of shame and frustration because of their past relationships with therapists and some have felt that they could not even do therapy right. Research has found that alexithymic traits like difficulty recognizing feelings is an important predictor of the severity of remaining depressive symptoms after psychotherapeutic treatment. Poor treatment outcomes may be associated with negative perceptions of alexithymic patients by their providers. This may lead to a devaluation of alexithymic patients by therapists or a belief that the patients are not a good fit for them. Many therapists working with alexithymic patients describe feelings of boredom or patients seeming closed off during sessions (Da Silva et al., 2018).
Alexithymia is not assessed or recognized in most clinical settings. The lack of consideration of alexithymia by health systems could explain findings in recent studies showing that 50% of all depression treatments are ineffective (Cuijpers et al., 2021). Patients with alexithymia show heightened suicide rates, decreased response to conventional treatment approaches like antidepressant medication and talk therapy. Some researchers believe that traditional depression treatment methods are not effective due to different structural brain differences associated with alexithymia patients compared other populations presenting with depressive symptoms (Förster et al., 2020).
With abnormally high occurrence of alexithymia in neurodiverse populations it is vital for healthcare providers to screen for the condition before determining treatment approaches. Recent studies found that antidepressants, increased alexithymic symptoms, increased depressive symptoms, resistance to antidepressant treatment, and higher rates of suicidality in neurodiverse adults with co-occurring alexithymia (Costa et al., 2020; Kiraz et al., 2020).
Our neurodiverse patients often report that antidepressants exasperate feelings of low life satisfaction and emotional blunting symptoms seen in alexithymia. A common feature that is poorly understood, little studied, and gets less attention is the 'emotional blunting' effect of antidepressant treatment. A survey of nearly 2000 adults who received antidepressant treatments found that more than half of the participants described emotional side effects. Specifically, feeling emotionally numb 60%, not feeling like oneself 52%, decrease in positive feelings 42%, and caring less about others 39% (Kajanoja et al., 2018). Among several of our patients it seemed that antidepressant treatment caused symptoms of alexithymia. Interestingly, once the medication was discontinued the symptoms dissipated.
Psychostimulant medications are most often prescribed to reduce symptoms of ADHD. One study noted additional benefits of psychostimulants including a decrease in alexithymia symptoms and an increase in emotional awareness over a 6-month period. Following the introduction of a psychostimulant medication highly alexithymic patients experienced significant decreases in alexithymia symptoms as well as improvements in emotional awareness. The promising result of the study indicates that pre-treatment with stimulant medication can strengthen patients with ADHD and alexithymia ability to integrate benefits from psychotherapy (Matuszak et al., 2013).
Researchers believe that dopamine dysfunction in the brain may be related to emotional-processing deficits associated with alexithymia. This supported by a high prevalence of alexithymia in patients with neurological disorders that feature dopamine dysfunction like Parkinson's disease and ADHD (Kiraz et al., 2020; Okita et al., 2016). This may explain the effectiveness of stimulant treatment for patients with alexithymia. We have observed this phenomenon with nearly two dozen of our patients with co-occurring ADHD and alexithymia. Following the discontinuation of their antidepressants and the addition of a stimulant they no longer meet criteria for alexithymia.
It is important for therapist to understand or at least screen for alexithymia. Most modern psychotherapeutic approaches emphasize emotional processes which can be detrimental to patients with alexithymia. For patients with alexithymia the inability to identify specific emotions, how something made them feel, or where emotions live in the body is not something that comes naturally to them or is it something they can will themselves to do. Their emotional deficits are physiological in nature. It would be like a medical doctor expecting a person paralyzed from the waist down to participate in treatment at an office that is not wheelchair accessible.
Research shows that traditional talk therapy techniques have made little impact on alexithymic patient lives, caused frustration among therapists, and is linked with poor psychotherapy outcomes (Aaron & , 2016). The inability to express the emotional nature of problems impair patients' capacity to efficiently communicate with therapists. Patients may present with vague complaints that make it difficult to establish treatment plans. Even after engaging in therapy for some time patients with alexithymia tend to articulate emotions as physical complaints and describe change in a more rational rather than emotional way (Da Silva et al., 2018).
Early intervention may potentially to reduce symptoms alexithymia. One study found that a curriculum designed to foster awareness, expression, and regulation of emotions improves social skills and academic performance among 5th and 6th graders with alexithymia. Another study demonstrated that a 4-week expressive writing model resulted in decreased doctor's visits, depression scores, and sleep disturbances among patients with elevated alexithymia. Research suggests that alexithymic populations with low interoceptive accuracy seem to respond well to interventions that focus attention on internal stimuli. While those with elevated alexithymia and high interoceptive accuracy can be susceptible to the development of somatic symptom disorders and will likely benefit less from body-focused therapeutic interventions (Aaron & , 2016).
Alexithymia is a complex condition that requires more attention within the medical and behavioral health communities. Better support for this population needs to begin at universities. Medical and behavioral programs must start educating aspiring clinicians on alexithymia and its impact on health. At the clinical level health systems must do a better job of screening for alexithymia, understanding its comorbidities, and developing interventions that address the unique features of the condition. If the current estimate that alexithymia impacts 13% of the population are true, nearly 44 million Americans have alexithymia. How many of them have been identified or treated? How many have been lost because it was not identified or treated?
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