Roots of Alexithymia

Review paper Archives of Psychiatry Research 2019;55:71-84 DOI: 10.20471/may.2019.55.01.06 Received September 26, 2018, accepted after revision March 25, 2019 Roots of Alexithymia Daniela Šago1, 2, Goran Babić3, 4 1 Psychiatric Hospital ‘Sveti Ivan’, Zagreb, Croatia, 2Faculty of Medicine, Josip Juraj Stross- mayer University of Osijek, Osijek, Croatia 3Croatian Psychoanalytic Society, Zagreb, Croatia,4 University of Zagreb, School of Medicine, Zagreb, Croatia Abstract - This paper presents the historical background and theoretical framework of alexithymia and the development of the instruments that measure this theoretical construct more accurately. The alexithymia concept was derived from clinical observation, initially formulated without an underlying theoretical framework. Nowadays, alexithymia is a part of the theory of cognitive processing and regulation of emotions. The paper also reviews the interest alexithymia aroused in research and clinical work of various fields of psychol- ogy, particularly psychoanalysis. The concept was developed from clinical experience with psychosomatic patients that responded poorly to psychotherapy. The development of the concept from categorical to di- mensional is highlighted. Alexithymia was conceptualised as a defense mechanism, but also as deficit pathology. It overlaps with the concept of mentalization and can be viewed both in terms of state and trait features. Finally, the measuring instruments for alexithymia are comprehensively listed. Keywords: alexithymia, psychoanalytic theory, psychosomatic disorder, the theory of mind, mentalizing Copyright © 2019 KBCSM, Zagreb e-mail: [email protected] • www.http://apr.kbcsm.hr Historical background and theoretical Clinical observation of alexithymia date framework of the alexithymia concept back to the 1940s [2]. Alexithymic deficits The term alexithymia (Greek; a = lack, lex- were described in patients with classic psy- is = word, thymos = emotion, mood, or feel- chosomatic diseases as well as in general ing) was coined by Sifneos and introduced in psychiatric patients, particularly in those re- the early 1970s to denote a cluster of features sponding poorly to psychoanalytic therapy including difficulty identifying and describing [3–6]. Reusch described affective and cogni- subjective feelings, a restricted fantasy life, tive disturbance due to developmental arrest and preoccupation with trivial aspects of ex- in early childhood when emotions are not well ternal events’ characteristics [1]. connected with words and expressed through bodily channels [3], while Kelman associated externalized living as modus vivendi [6]. Mar- ty and de M’Uzan’s [7] introduce a concept Correspondence to: Daniela Šago Psychiatric Hospital ‘Sveti Ivan’, Jankomir 11, 10 090 Zagreb, of pensée opératoire (operative thinking), de- Croatia noting the absence of fantasy and other man- Phone: +385-91-3211500; E-mail: [email protected] ifestation of the depleted inner mental world 72 of feelings, ideas about intentions, needs, at- pean Conference on Psychosomatic Research titudes and focused on external events. They in Heidelberg, Germany. At the meeting, Sif- also suggested a vulnerability to somatic ill- neos told attendees that ‘The word was sim- ness. Marty [8, 9] attributed it to a deficien- ply used to describe certain clinical observa- cy in mentalization – a concept introduced tions that were made over very many years. I in the early 1960s. Almost simultaneously, tried appropriately to use a Greek word or a Krystal independently described similar ob- pseudo-Greek word for descriptive purposes’ servations among patients with substance use [21]. Alexithymia engulfs a disturbance in af- disorders and posttraumatic states [10, 11]. fective and cognitive functions and is char- Krystal first highlighted alexithymia as possi- acterized by a difficulty recognizing and ver- bly the most critical single factor diminishing balizing feelings, and a paucity of fantasy [1]. the success of psychoanalysis [12]. Rubins Nemiah and colleagues made the distinction emphasized that Horney was the first to label between emotions and feelings [21]. Emo- these patients as alexithymic [5, 13]. McDou- tions have the neurophysiological component gall referred to these individuals as normo- and the component of motor-expression of paths, dis-affected and anti-analysands, and affect. Both components must have mental she warned of prolonged periods of stag- representations before the conscious experi- nation in therapy [14–16]. In 1967 Sifneos ence of feelings [20]. More recently Damasio reported his preliminary observations on emphasized the same conceptual distinction some patients’ distress from psychosomatic and highlighted that emotions precede feel- illnesses [16]. He recognized that they have ings [22]. Sifneos and Nemiah pointed out no pathology of conflict as neurotic patients that alexithymia is not an absence of emo- have, but rather show deficits in the abil- tions, but rather a deficit in elaborating feel- ity to experience feelings. In the subsequent ings [16]. Nemiah, Freyberger and Sifneos three years, Nemiah and Sifneos conducted also reported that ‘Although many individuals a more systematic examination of previous- may initially speak of being nervous, or sad, ly tape-recorded interviews of patients with or angry, if they are pressed to describe their two of the following classic psychosomatic feelings further and to tell the examiner what diseases specified by Alexander (duodenal being sad or nervous or angry feels like, it rap- ulcer, bronchial asthma, rheumatoid arthri- idly becomes apparent that they are totally un- tis, ulcerative colitis, hypertension, hyperthy- able to do so’ [20]. Many psychoanalysts and roidism, and atopic dermatitis) [17–19]. Their psychotherapists observed that those patients conclusion was that these patients have diffi- are deficient in specific psychological capaci- culty in describing and identifying their feel- ties and do not respond well to traditional in- ings. Also, many of these patients showed a terpretative psychotherapies [5, 6, 23]. thought content consistent with the concept of pensée opératoire. In the seminal publica- Lack of love, joy, and happiness tion, Nemiah, Freyberger, and Sifneos fully We can imagine an alexithymic person as explicated core features of alexithymic indi- an individual who lacks psychological mind- viduals [20]. The year 1976 was defining for edness, demonstrates a minimal interest in the alexithymia construct, when it was se- play and has concreteness in dreaming and lected as the central theme of the 11th Euro- thinking; someone who has limited aware- Archives of Psychiatry Research 2019;55:71-84 Šago, Babić 73 ness of emotions and drives, and a utilitarian psychosomatic illness, the French psycho- style of living, whose behavior is guided by somatic school introduced the concept of rules instead of inner feelings, fantasies, and mentalization [8, 9, 31]. During the 1990s, wishes. When attending psychoanalytic ther- Lecours and Bouchard extended the contri- apy, an alexithymic individual fills the session butions of Marty and other French analysts with a monotonous chronological recital of by proposing a hierarchical conceptual mod- external events and is unable to engage in psy- el with levels of mentalization which shows chotherapeutic therapy, provoking feelings of some similarities to Krystal’s theory of af- dullness and boredom in the therapist. Hence, fects and Lane and Schwartz’s hierarchical it is very likely that alexithymia will be associ- model of levels of emotional awareness [28, ated with less improvement in psychotherapy 32, 33]. It was around that time when Fonagy [24]. The alexithymic individual has a limited and Target adopted the concept of mental- ability to experience pleasurable emotions ization and defined it more broadly as the ca- such as joy, love, and happiness [25, 26]. Krys- pacity to think about one’s own and others’ tal conceptualized the course of maturation mental states regarding feelings, desires, and of emotions as a progressive desomatisation intentions [34, 35]. More recently, Fonagy, also linked to learning of words and subse- Bateman and Luyten described mentaliza- quently differentiated into different subjective tion as a multifaceted construct with cogni- feelings [27]. Furthermore, the failure to link tive and affective components and indicated feelings with fantasies and to reflect on inner that mentalizing is not granted and constant experience pushes the mind toward a preoc- capacity of the mind, but is in constant flux cupation with the details of external events, and dynamic and interplay context of specif- which is characteristic of pensée opératoire ic attachment relationships is also influenced [28]. With alexithymia, the emotions are still by the level of distress in specific moments felt, but the connections with words and im- [36]. According to Taylor and Bagby the way ages are interrupted, the emotions are poorly that Fonagy understands mentalization [36], represented at higher levels of consciousness, and the way Lane applies it, is very different resulting in a deficit of conscious feelings and from how it was conceptualized originally by difficulties in identifying and verbalizing feel- French psychoanalysts [8, 9, 23, 31, 36, 37]. ings. It is likely that individuals with difficulty Lane and colleagues argue that scientific de- identifying, verbalizing, and reflecting on feel- velopments since the 1970s, including the ings

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