By Professor Tony Attwood and Dr Michelle Garnett
Introduction
Alexithymia refers to a difficulty recognising and accurately labelling different emotions and body sensations. A person with alexithymia can tell if they are feeling a “good” emotion or a “bad” emotion but could not necessarily tell you what they are feeling more accurately. For example, recently a woman in our Clinic described a situation for her that was “ick.” When we tried to understand what “ick” meant, she could not say anything further than it was a “bad” feeling and she did what she could to avoid it. As we explored the context for her emotion it was clear that she had experienced embarrassment or shame.
Primary and secondary alexithymia were first discussed by Freyberger in 1977. Most research has studied primary alexithymia as a stable personality trait which is predictive of certain emotional difficulties (e.g., Bird & Cook, 2013a, 2013b). Other researchers (for example, Zeitlin et al, 1993) have proposed that alexithymia is a secondary condition that emerges as a coping mechanism to acute psychological stress including trauma. It is likely that both occur.
When alexithymia was first described by Nemeiah in 1976 the definition included having a thinking style that was externally oriented in addition to a poor capacity for fantasizing or symbolic thought. Over the past 12 years of research into alexithymia the predominant assessment measure has been the Toronto Alexithymia Scale (TAS; Bagby, Parker & Taylor, 1994) which does not measure these components. Hence, our current understanding of alexithymia and its role in emotions is based on the simplified definition of alexithymia as a difficulty in recognising and labelling emotions and body sensations.
Alexithymia and Emotions
There have been several recent studies finding a link between certain mental health conditions and alexithymia. For example, women with alexithymia had a 2.6 times greater risk of experiencing depression during pregnancy than women who did not have alexithymia (Gilanifar & Delavar, 2016). In a prospective study (Günther et al., 2016) measured alexithymia in a group of depressed inpatients at the start of hospitalisation, and then after treatment. High alexithymia scores were predictive of continued depression after hospitalisation.
In addition, there is much research now to show an association between alexithymia and other mental health conditions including suicidality, obsessive-compulsive disorder, post-traumatic stress disorder, adjustment disorder, binge eating disorder, schizophrenia, traumatic brain injury, and substance abuse (for a review see Hemming et al, 2019). In an Australian psychiatric sample alexithymia was several times more prevalent than in the general community (McGillivray et al, 2017).
Many of the studies reviewed are not prospective, but those that are show evidence for primary alexithymia (i.e., Günther et al., 2016), that is, that having alexithymia is predictive of developing a mental health condition. Other studies show that treatment of mental health conditions decreases alexithymia, hence providing evidence of secondary alexithymia (e.g., Fukunishi, 1997).
Alexithymia and Autism
A recent meta-analysis of 15 high quality studies on alexithymia and autism (Kinnaird, Stewart & Tchanturia, 2019) found that estimates of co-occurrence of the conditions ranged between 33.3 and 63%. Overall, the prevalence of alexithymia was much higher in autism at 49.93% than in neurotypicals at 4.89%.
Bird and Cook (2013a) propose that the higher rate of mental health issues in autism, specifically, anxiety and depression may be due to co-occurring alexithymia, rather than being due to autism per se. Their “alexithymia hypothesis” predicts that the group of autistic people who do have alexithymia would have more emotional difficulties than those who don’t. There is research evidence to show this (Cook, Brewer, Shah & Bird, 2013b).
Autism, Alexithymia and Emotions
Alexithymia is a separate condition to autism, depression, and anxiety, but research indicates that if you are autistic, you are more likely to have alexithymia, and if you have alexithymia, you are more likely to develop a mental health condition, whether you are autistic or not.
Given the research to date, it is important to understand if alexithymia is a part of the person’s profile, firstly because treating alexithymia may prevent that person developing emotional processing difficulties. Secondly, it has frequently been noted that having alexithymia can interfere with engagement in psychotherapy, making it difficult to treat the emotional difficulties (Taylor, 1984). Lastly, if alexithymia is causal to emotional difficulties for some people, it, makes sense to directly treat the underlying cause.
Interestingly, alexithymia has decreased as a result of therapy for other conditions, as a by-product of therapy. For example, Rufer et al, (2010) found alexithymia scores decreased because of a short-term cognitive behaviour therapy programme for panic disorder.
How do you Assess for Alexithymia?
Alexithymia is typically assessed using a self-report questionnaire. As mentioned above, the most commonly used scale is the Toronto Alexithymia Scale, which is freely available online. There is also the Perth Alexithymia Questionaire (Preece et al, 2018), which is also freely available online.
Both of these measures were developed for use with adolescents and adults.
There is also an Alexithymia Questionnaire available to assess alexithymia in children.
How do you Treat Alexithymia?
As discussed, for some people alexithymia may be secondary to emotional difficulties, and perhaps for these people alexithymia resolves when the primary issue, for example, the depression or the anxiety disorder, is treated.
However, for others the primary issue is alexithymia, and it makes sense to directly target alexithymia for treatment. Cameron et al (2014) undertook a review of studies that targeted alexithymia for change directly using psychological interventions. The interventions that showed the most success for ameliorating alexithymia were those that used psychoeducational approaches with skills training to increase affect awareness. Therapies that focussed on identifying, describing, and understanding both emotional states and bodily sensations, were the most effective. It was not enough to know about emotions and bodily sensations intellectually. There needed to be an exposure element, where the person would feel what they feel in the session, and be guided to describe the sensations, to identify the words, and be taught ways to cope with any unpleasant body sensations. Successful therapies also included increasing attention to body sensations that triggered affect, using a range of methods, including hypnosis, relaxation strategies and mindfulness.
Interestingly only one study reviewed in the research directly studied whether a reduction in alexithymia led to an increase in using the emotional information to guide adaptive behaviour. In this study (Ogrodniczuk et al, 2010) the researchers directly examined whether increased emotional awareness affected social relationships. They found that it did, i.e., those whose alexithymia scores decreased showed better interpersonal functioning both during treatment and at follow-up. This is a promising finding that has direct implications for treatment of mental health issues in autistic people, for whom social communication difficulties are a key part of their profile.
Summary and Where to From Here
Although alexithymia was first described in the 1970’s there has been an increase in research into the phenomenon over the past 12 years. This research shows that alexithymia is a primary cause of emotional processing difficulties, resulting in mental health problems, or can be secondary to mental health issues. Approximately 50% of autistic people also have alexithymia, and this group may experience poorer mental health than autistic people who do not have alexithymia.
Assessing and treating alexithymia is possible and seems desirable, to increase positive long-term outcomes of therapy. Specifically targeting alexithymia for treatment is recommended, particularly if alexithymia is primary, both for prevention of mental health problems, but also for long-term recovery. Treating alexithymia directly seems to not only assist the person with recovery from their mental health problems but also to improve their interpersonal functioning.
If you are interested in learning more about alexithymia and its relationship to autism, we highly recommend our online courses, Diagnosis for Autistic Girls and Women and Emotion Management for Autistic Children and Adolescents.
References:
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