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Alexithymia
Alexithymia MG Haviland, Loma Linda University School of Medicine, Loma Linda, CA, USA r 2016 Elsevier Inc. All rights reserved.
Glossary Anterior cingulate cortex Midline cortical structure involved in many processes, including cognition, emotion, pain, and attention. Bifactor model A factor model that specifies a general factor believed to influence all items and three or more orthogonal group factors that account for residual common variance. Classic psychosomatic diseases Seven medical conditions (e.g., peptic ulcer) thought in the 1950s and 1960s (but no longer) to be caused by stress or psychological factors. Emotional intelligence The ability to perceive, use, understand, and manage emotions.
History To characterize classic psychosomatic patients who could neither describe nor differentiate their feelings or elaborate their fantasies, psychiatrist Peter Sifneos coined the word ‘alexithymia’ for the set of cognitive–affective characteristics that he and his Harvard Medical School colleague, John Nemiah, had observed and systematically evaluated. Sifneos drew on Greek (a [lack], lexis [word], and thymos [emotion]) to name this cluster of features, which also included a preoccupation with the trivial aspects of external events and a proclivity to describe them in considerable and boring detail (Nemiah and Sifneos, 1970; Sifneos, 1973, 1967). Concurrently, but independently, Krystal (1968) observed these characteristics in patients who had experienced traumatic stress or were drug dependent (Krystal and Raskin, 1970; see also Krystal, 1988), as did Bruch (1973) in anorexia nervosa patients and Wurmser (1974) in narcotic-addicted patients. Clinical observations of alexithymia, although not yet named, date back to the 1940s. Alexithymic deficits, for example, were described in patients with classic psychosomatic diseases as well as in general psychiatric patients, and particularly in those responding poorly to psychoanalytic therapy (Ruesch, 1948; Maclean, 1949; Horney, 1952; Kelman, 1952). Moreover, the absence of fantasies and the externally oriented cognitive style that Sifneos and Nemiah observed already had been documented by Marty and de M’Uzan (1963) in physically-ill patients and labeled, la pensee operatoire (operative thinking). After years of clinical observation, however, the defining year for the alexithymia construct arrived in 1976 when it was selected as the main theme for the 11th European Conference on Psychosomatic Research in Heidelberg, Germany, and it was fully explicated by Nemiah et al. (1976). In this seminal publication, they described the characteristics of alexithymic individuals, including those many now assert as its core features (Taylor and Bagby, 2012, 2013a,b): (1) difficulties identifying and differentiating feelings, (2) difficulties
Encyclopedia of Mental Health, Volume 1
Epigenetics Genetic processes involving the interactions of genetic material and the environment that change the expression of a gene but do not alter the deoxyribonucleic acid (DNA) sequence. La pensee operatoire External (operative) thinking; thought content that is utilitarian and devoid of fantasy. Mentalization The ability to recognize one’s own mental states (e.g., beliefs, intentions, and desires) and those of others. Psychological mindedness One’s capacity to genuinely understand the interrelationships among thoughts, feelings, and actions of self and others. Q-sort method A person-versus variable-centered approach to personality assessment.
describing feelings, (3) impoverished fantasy lives, and (4) an externally oriented cognitive style (the latter two corresponding to la pensee operatoire). It is important to note, however, that individuals with alexithymic deficits can have outbursts of sadness or rage, which may seem to be at odds with the definition, but they have no understanding of these strong emotional expressions (Taylor et al., 1997). Primary versus secondary alexithymia was a distinction made many years ago, with primary alexithymia thought to reflect ‘structural or neurobiological defects’ and secondary (acquired) alexithymia seen as emerging from ‘developmental arrests or from a catastrophic environmental onslaught’ (Sifneos, 1987, p. 123; see also Sifneos, 1983), or a reaction to life-threatening illness or medical treatment (Freyberger, 1977; Lumley et al., 2007). As Taylor et al. (1997) have underscored, however, regardless of etiology, alexithymia is not ‘simply’ emotional non-expression in the face of situational stressors that clears when stress abates (see also Taylor and Bagby, 2012, 2013a,b); rather, alexithymic deficits are profound and enduring (Krystal, 1988; van der Kolk et al., 1996). Contemporary theory and research suggest that several factors – structural, functional, epigenetic, for example – can contribute to the development of alexithymia (Berthoz et al., 2011; Krystal, 1988; Taylor et al., 1997). By the early/mid-1980s, alexithymia’s definition (above) and its consequences (e.g., vulnerability to a variety of illnesses as well as poor treatment responses), summarized at the time by Taylor (1984) seemed at least somewhat clear based on clinical observations. The construct, nevertheless, needed empirical exploration and, as new information became available, refinement (Lesser and Lesser, 1983).
Modern Definitions and Measurement Jack Block, in his preface to Personality as an Affect-Processing System: Toward an Integrative Theory wrote, “… the field of
doi:10.1016/B978-0-12-397045-9.00227-5
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personality research continues inchoate… It is lively, conceptually multilingual, empirically prolific, contentious, ambitious, and unsatisfying.” (Block, 2002, p. xi). Such is an apt description of the present state of alexithymia research. Efforts to validate the alexithymia construct through research and measurement began in earnest in 1985. Although progress in both theory and measurement has occurred (Berthoz et al., 2011; Taylor and Bagby, 2012), various issues continue to spark. Self-report is the most common assessment method, for example, despite the availability of structured/semi-structured interviews and observer-rated measures, the clear and persistent recommendations to use multiple assessment methods (in general, see Funder, 1999; in alexithymia research, Taylor and Bagby, 2012), and doubts about whether individuals with alexithymic deficits are sufficiently equipped to rate their own deficits (Lane et al., 1999; Sifneos, 1996). In response to debates about measurement shortcomings, researchers have developed a variety of instruments, which are described along with item content/conceptual coverage in Table 1. Reviews of these are available (e.g., Lumley et al., 2007; Taylor and Bagby, 2012; Taylor et al., 1997, 2000) as studies of the interrelationships among measures (e.g., Berthoz et al., Table 1
2007; Dorard et al., 2008; Lumley et al., 2005; Meganck et al., 2011). Many alexithymia measures have been translated into several languages. All have ‘passed’ various, conventional psychometric tests and appear not to have the same limits of the earliest measurement attempts (Taylor et al., 1997). With occasional exceptions, the relationships among measures are as expected, given comparisons within and across methods.
Self-Report Scales The Twenty-item Toronto Alexithymia Scale (TAS-20; Bagby et al., 1994a,b), the third in the family of Toronto Alexithymia scales, is far and away the most popular measure. With a few exceptions, research supports the TAS-20’s three-factor structure (Parker et al., 2003; Taylor et al., 2003): difficulty identifying feelings, difficulty communicating feelings, and external thinking (external-thinking indirectly taps restricted imagination). Consistent with their view that alexithymia is dimensional (versus categorical), the test authors recommend using total TAS-20 scores as a continuous measure of alexithymia severity. Nevertheless, cut-off scores for ‘alexithymic’ and
Alexithymia measures
Instrument and source
Item content/conceptual coverage
Self-report Twenty-item Toronto Alexithymia Scale (TAS-20); Bagby et al., 1994a,b Bermond–Vorst Alexithymia Questionnaire (BVAQ); Vorst and Bermond, 2001
Difficulties identifying and differentiating feelings, difficulties describing feelings, an externally oriented cognitive style (and indirectly, reduced fantasy) Not emotional in emotion-provoking situations; limited fantasy and imagination; failures in identifying, analyzing, and verbalizing one's emotional states
Structured interview Toronto Structured Interview for Alexithymia (TSIA); Bagby et al., 2006a Diagnostic Criteria for Psychosomatic Research, Alexithymia (DCPR-A); Fava et al., 1995 Semi-structured interview Modified Beth Israel Hospital Psychosomatic Questionnaire (modified-BIQ); Bagby et al., 1994b California Q-set Alexithymia Prototype (CAQ-AP)b; Haviland and Reise, 1996
Observer report Observer Alexithymia Scale (OAS); Haviland et al., 2000c
Projective test Rorschach Alexithymia Scale (RAS); Porcelli and Mihura, 2010 Self-report/rater scored (indirect measure) Levels of Emotional Awareness Scale (LEAS); Lane et al., 1990 a
Difficulty identifying feelings, difficulty describing feelings to others, externally oriented thinking, and reduced fantasy/poor imagination Difficulties verbalizing and communicating emotional states, reduced fantasy, external thinking, physical reactions to strong emotions; outbursts of anger, crying, or joy (without understanding) Difficulties with the identification and verbal communication of feelings; poor imaginal activity, operatory thinking Difficulties experiencing and expressing emotion; poor interpersonal relationships; not warm or compassionate; lacking imagination and humor; neither introspective nor insightful; health worries; being literal, socially conforming, and utilitarian; anxiety and tension find outlet in bodily symptoms Lacking skill in interpersonal matters and relationships; poor stress tolerance, insight, and self-understanding; health concerns and physical problems; without imagination or humor; rigidity, excessive self-control Low awareness of affective states, poor fantasy, concrete/simplistic thinking; conventionality, social conformity; limited adaptive resources, difficulty managing interpersonal relationships Differentiation, specificity, and blending of emotions
Interviewers may be lay or professional, preferably trained in instrument administration and scoring, and familiar with the alexithymia construct. Lay or professional raters; interview not required if rater knows target well (may also be used as a self-report measure). c Lay or professional raters who know target well. b
Alexithymia ‘non-alexithymic’ have been established (Taylor et al., 1997), and they are used most effectively in time-consuming and expensive experimental and neuroimaging studies of cognition and affect (i.e., extreme groups method; see Berthoz et al., 2011; Grynberg et al., 2012; Moriguchi and Komaki, 2013). In response to the TAS-20’s multidimensional structure, researchers often calculate total and subscale scores and evaluate all relationships with external correlates, a practice that has presented interpretive challenges. Use of the TAS-20 in structural equation modeling (SEM/causal modeling) is inconsistent, too; sometimes all items are used, but other times items from only one or two subscales are used. Reise et al’s. (2013) bifactor modeling work supports the TAS-20 authors’ recommendation to use total TAS-20 scores (in general and in SEM) to represent alexithymia, given a relatively strong general factor, alexithymia. The Bermond–Vorst Alexithymia Questionnaire (BVAQ, Vorst and Bermond, 2001) was developed in response to what its authors believed to be incomplete conceptual coverage in the TAS-20 item pool. They appeared unpersuaded that external thinking adequately represented diminution of fantasy and suggested adding items to represent ‘reduced experiencing of emotional feelings.’ BVAQ data are used in two ways: (1) total scores as a continuous measure of alexithymia severity and (2) subscales to create ‘types” (combinations of high and low ‘cognitive’ and ‘affective’ components), although the latter practice has been met with some controversy (Berthoz et al., 2011; Taylor and Bagby, 2012; see also Bagby et al., 2009).
Interviews and Observer Ratings The Toronto Structured Interview for Alexithymia (TSIA; Bagby et al., 2006) was developed in response to repeated calls for multi-method alexithymia assessment, interviewer/observerrated measures, and direct measurement of reduced fantasy. It explicitly taps the aforementioned four defining features of alexithymia with 24 items rated on a 0–2 scale (six items for each feature with accompanying prompts/probes). Psychometric data are consistent across studies and support its use (Bagby et al., 2006; Caretti et al., 2011; Grabe et al., 2009). The Diagnostic Criteria for Psychosomatic Research, Alexithymia (DCPR-A; Fava et al., 1995) assesses 12 psychosocial syndromes clustered into five diagnostic rubrics, one of which is alexithymia. If individuals meet the established criteria for alexithymia, they are given the diagnosis. Used largely in European studies, its value in characterizing alexithymia in the medically ill, for example, is illustrated in Porcelli et al. (2013). The Modified Beth Israel Hospital Psychosomatic Questionnaire (modified-BIQ; Bagby et al., 1994b) is a revision of the original Beth Israel Hospital Psychosomatic Questionnaire (BIQ; Sifneos, 1973). The modified-BIQ is used only occasionally in contemporary research and mostly in psychometric studies (e.g., Bagby et al., 1994a,b; Haviland et al., 2002). The California Q-set Alexithymia Prototype (CAQ-AP; Haviland and Reise, 1996) was developed both to define and to measure alexithymia. The authors used the Q-sort method (Block, 2008) to construct the CAQ-AP. Thirteen alexithymia researchers – including seminal contributors to the field – described the personality characteristics of the prototypic
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‘alexithymic’ person with CAQ items to generate a consensus prototype. Conceptual coverage in the prototype is very good; in fact, John Nemiah wrote, “… of all the standardized measures, the CAQ-AP seems to me to provide the most accurate and complete description of alexithymia as it was first conceived of from clinical observation.” (J.C. Nemiah, personal communication, January 27, 1997). The Observer Alexithymia Scale (OAS; Haviland et al., 2000, 2001, 2002) was developed so that clinicians, family members, and acquaintances could provide alexithymia ratings (and ratings could be averaged across multiple informants). Item content, written in ordinary language, is from the CAQ-AP. Bifactor modeling has shown a strong general factor, alexithymia (Reise et al., 2010), and, thus, the authors recommend using total OAS scores to assess the construct.
Projective Technique The Rorschach Alexithymia Scale (RAS; Porcelli and Mihura, 2010) represents an effort to improve on Porcelli and Meyer’s (2002) original Rorschach-alexithymia work. The authors believe that the RAS is useful in clinical settings in which Rorschach testing is routine. Psychometric and applied work is needed, however, to support this expectation.
Measuring Emotional Awareness The Levels of Emotional Awareness Scale (LEAS; Lane et al., 1990) corresponds to Lane and Schwartz’s (1987) theory of emotional awareness (i.e., the ability to recognize and describe one’s emotions and those of others). The LEAS distinguishes between implicit/unconscious and explicit/conscious emotional awareness levels, and it has proven useful for conceptualizing and measuring alexithymia. Lane et al. (1999), for example, have proposed that alexithymia ‘represents a deficit in the conscious experience of emotion’ (p. 837) and, in fact, may be thought of as the emotional equivalent of blindsight or an impairment in knowing what one is feeling (more recently labeled affective agnosia). They contrast this with the more common alexithymia definition, a deficit in one’s ability to put feelings into words. Theoretical and empirical support comes from studies of the anterior cingulate cortex (i.e., its participation in processing emotional cues) (see Berthoz et al., 2011; Lane et al., 1998). The LEAS and the TAS-20 generally do not correlate well, but each has its place in alexithymia research (see recommended uses in Subic-Wrana, et al. (2005)).
Summary Overall, a fair amount of conceptual and item overlap (i.e., consensus) across the various direct alexithymia measures emerges, as shown in Table 1. Among the issues that remain unclear, however, are whether (1) the TAS-20 adequately taps reduced fantasy, (2) the ‘BVAQ factor,’ ‘reduced experiencing of emotional feelings,’ is justifiable/necessary (in other words, is it a defining feature), (3) it is appropriate to create alexithymia ‘types’ from BVAQ scores, and (4) social conformity is a defining versus an associated feature (see CAQ-AP and RAS item content). Finally, how best to use the TAS-20 and the
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Alexithymia
LEAS in alexithymia research (and integrate findings across studies) is not entirely clear. Nowhere is this more apparent than in reviews of neuroimaging studies (e.g., Berthoz et al., 2011; Kano and Fukudo, 2013; Moriguchi and Komaki, 2013); drawing clear conclusions is difficult. Given the stated need for multi-method alexithymia assessments and the variety and demonstrated suitability of the available alexithymia instruments, it is unfortunate that researchers typically choose the convenience of a single self-report, the TAS-20 (and score it in a variety of ways). Moreover, in studies in which more than one measure is used, the objectives often are to determine the correlations between the measures (with the TAS-20 as a standard) and subsequently to decide whether the less popular measures are ‘valid’ (in other words, correlate moderately, at least, with the TAS-20) or ‘work’ as well as (or better than) the others. Clearly, using more than one instrument or method to assess a construct presents its own set of challenges (Funder, 1999), but advancing the field demands these challenges be faced. Although researchers recognize this (see calls for multi-method assessments in most articles’ discussion sections), they have been slow to make such investments.
Relationships with Other Constructs In the course of evaluating a less well-established construct, researchers often compare it with related constructs, as well as with the basic dimensions of personality. The relationship between alexithymia, emotional intelligence, and various traits involving access to and use of feelings (and recognizing those of others) – for example, psychological mindedness and mentalization – is well summarized in Bar-On and Parker (2000) and Taylor and Bagby (2012). This is a relatively large body of work, and the studies are theoretical and empirical (empirical work largely involves correlations between self-report scales). The general conclusion – albeit an oversimplification – is that alexithymia relates to (and to some extent, overlaps with) these various emotion recognition/use constructs, but that it is sufficiently distinct from each of them.
Alexithymia and the Basic Dimensions of Personality Researchers have studied alexithymia’s relationships to the basic dimensions of personality to evaluate alexithymia’s place in the study of personality, affects, and emotion (see also Block, 2002; Magai and McFadden, 1995). Notable examples include the Five-Factor Model (FFM, neuroticism, extraversion, openness, conscientiousness, and agreeableness; Costa and McCrae, 1992) and the Two-Factor Model (ego-control and ego-resilience; Block and Block, 1980). Taylor and Bagby (2012, 2013a), for example, have reviewed studies of the relationship between self-report TAS-20 and NEO Personality Inventory/NEO PI-R scores (Costa and McCrae, 1992) scores. In general, TAS-20 are associated with higher neuroticism broad-trait and facet scores and negatively with broad-trait and facet scores for extraversion and openness. These relationships are unsurprising, as alexithymic individuals correspondingly are seen as unhappy and lacking
emotional stability, not outgoing/social, and not curious, creative, or imaginative. Although a popular and useful framework, the FFM does not hold universal appeal nor does the reliance on self-report in personality assessment (Block, 1995). These misgivings, in part, prompted Haviland and Reise (1996) to develop the CAQ-AP and to compare it to the theoretical prototypes for ego-control (over- and under-control) and ego-resilience. Egocontrol is the expression/inhibition of impulse, and egoresilience is the capacity to contextually modify one’s level of ego-control in response to situational demands. As predicted, the CAQ-AP was correlated moderately with the overcontrol prototype and more strongly with the ego-brittle prototype. Prototypic overcontrolling and ego-brittle people, however, appear not to have the difficulties prototypic alexithymic individuals have in cognitively processing and attaching meaning to emotional stimuli or telling other people what they are feeling. Haviland and Reise (1996) believe that these data support the uniqueness of the alexithymia construct.
Alexithymia and Psychopathy Haviland et al. (2004) used the CAQ-AP to evaluate the relationship between alexithymia and psychopathy. To clarify the relationship between the two constructs, they compared theoretical prototypes (Block, 2008), the CAQ-AP with the CAQPsychopathy Prototype (CAQ-PP; Reise and Oliver, 1994). Prototypic alexithymic and psychopathic persons were found to be quite different. Traits that stand out for alexithymia are anxious, overcontrolled, submissive, boring, ethically consistent, and socially conforming, whereas those standing out for psychopathy are anxiety-free, undercontrolled, dominant, charming, deceitful, and nonconforming. Such clarity is elusive when one depends solely on correlating self-report scales (preceding and subsequent studies of alexithymia and psychopathy have yielded surprising, inconsistent, and difficult-tointerpret results).
Medical/Psychiatric Diagnoses and Treatment From the earliest clinical observations to present day reviews and empirical studies, the association between alexithymia and psychiatric/medical illnesses is quite consistent (Lumley, 2004; Lumley et al., 2007; Porcelli et al., 2013; Taylor and Bagby, 2012; Taylor et al., 1997). To this day, alexithymia is associated with, for example, anxiety, mood, and eating disorders; substance abuse and dependence; and chronic pain (including irritable bowel syndrome and fibromyalgia). Also associated with alexithymia are various medical disorders, notably hypertension and rheumatoid arthritis, and studies of alexithymia and autism spectrum disorders and traumatic brain injury are underway (Berthoz et al., 2013; Neumann et al., 2014). How alexithymic deficits are related to these illnesses is varied and complex (Kano and Fukudo, 2013; Lumley, 2004; Lumley et al., 1996, 2007; Taylor et al., 1997). Poor health among alexithymic individuals, for example, may be related to altered autonomic, endocrine, and immune activity. Moreover,
Alexithymia
individuals with severe alexithymic deficits attempt to regulate affects with drugs, alcohol, and compulsive behaviors and often make other damaging life choices (e.g., poor nutrition and exercise, and delays in treatment-seeking). As noted, alexithymic deficits also are associated with the failure to recover from various associated diseases. Unfortunately, evidence-based guidance about how best to address alexithymia in clinical settings is limited. Several clinician/researchers have offered suggestions (e.g., supportive vs. insightoriented therapy) (Krystal, 1979, 1988; Lumley, 2004; Taylor and Bagby, 2013b; Taylor et al., 1997). Outcome data are scarce, but some, at least, are encouraging (Lumley, 2004; Taylor and Bagby, 2012).
Conclusion Alexithymia is an intriguing topic, one that in 40 years has generated voluminous research. Although researchers and clinicians have made gains in conceptualizing and assessing alexithymia, considerable construct validity work remains. Debates about the definition and measurement of alexithymia continue, its etiology has not been established firmly, understanding of its links to physical disease (origins and treatment) is incomplete, and its neural correlates remain uncertain. Although these gaps are sobering, alexithymia work, nevertheless, holds promise. Thus, this entry ends with suggestions for creating more certainty and, perhaps, wider acceptance of the construct.
Recommended Research 1. Use more than one instrument to measure alexithymia (preferably one interviewer/observer measure) and find ways to integrate these complementary rather than competing approaches, rather than simply pit one against the other and choose the ‘best’ results. 2. Consider bifactor modeling (see Reise, 2012) as instruments are proposed, evaluated, and applied. Despite the demonstrated multidimensional structure of several alexithymia instruments, researchers’ main interest is to evaluate alexithymia. Thus, it is critical to know whether there is a strong general factor and also whether subscales provide any reliable information that is unique from the general factor. 3. Conduct studies of alexithymia and social conformity. It appears in several conceptualizations (see Table 1) but was dropped as a defining feature. 4. Use alexithymia as a mediator in studies of maltreatment/ trauma and health outcomes in cases, for example, where researchers might use other measures of emotion dysregulation or posttraumatic stress disorder (presence/absence or symptom severity). 5. Expand theoretical explorations by comparing the CAQ-AP to available CAQ prototypes, which can illustrate conceptual similarities and differences. Many have been developed for theoretical constructs and diagnostic labels (e.g., antisocial personality, narcissism, and depression), and others can be constructed.
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6. Finally, use alexithymia to represent emotion processing deficits when evaluating contemporary approaches to treating, for example, eating, substance use, and pain disorders.
See also: Adult Victims of Intimate Partner Violence: Mental Health Implications and Interventions. Alcohol Use Disorders. Behavioral Addiction. Child Maltreatment. Chronic Fatigue Syndrome: A Biopsychosocial Perspective. Eating Disorders. Emotional Intelligence. Empathy. Marijuana: Medical Applications, Recreational Use and Substance Abuse Disorders. Personality and Personality Development. Personality Assessment. Posttraumatic Stress Disorder. Psychopathy. Rape and Sexual Assault. Self-Regulation. Somatic Symptom Disorder. Substance Abuse: Drugs.
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Magai, C., McFadden, S.H., 1995. The Role of Emotions in Social and Personality Development: History, Theory, and Research. New York, NY: Plenum Press. Marty, P., de M’Uzan, M., 1963. La “pensee operatoire”. Revue Francaise de Psychanalyse 27, 1345–1356. Meganck, R., Inslegers, R., Vanheule, S., Desmet, M., 2011. The convergence of alexithymia measures. Psychologica Belgica 51, 237–250. Moriguchi, Y., Komaki, G., 2013. Neuroimaging studies of alexithymia: Physical, affective, and social perspectives. BioPsychoSocial Medicine 7 (8), 1–12. doi:10.1186/1751-0759-7-8. Nemiah, J.C., Freyberger, H., Sifneos, P.E., 1976. Alexithymia: A view of the psychosomatic process. In: Hill, O.W. (Ed.), Modern Trends in Psychosomatic Medicine, vol. 3. London: Butterworths, pp. 430–439. Nemiah, J.C., Sifneos, P.E., 1970. Affect and fantasy in patients with psychosomatic disorders. In: Hill, O.W. (Ed.), Modern Trends in Psychosomatic Medicine, vol. 2. London: Butterworths, pp. 26–34. Neumann, D., Zupan, B., Malec, J.F., Hammond, F., 2014. Relationships between alexithymia, affect regulation, and empathy after traumatic brain injury. Journal of Head Trauma Rehabilitation 29, E18–E27. Parker, J.D., Taylor, G.J., Bagby, R.M., 2003. The 20-item Toronto Alexithymia Scale. III. Reliability and factorial validity in a community population. Journal of Psychosomatic Research 55, 269–275. Porcelli, P., Guidi, J., Sirri, L., et al., 2013. Alexithymia in the medically ill. Analysis of 1190 patients in gastroenterology, cardiology, oncology, and dermatology. General Hospital Psychiatry 35, 521–527. Porcelli, P., Meyer, G.J., 2002. Construct validity of Rorschach variables for alexithymia. Psychosomatics 43, 360–369. Porcelli, P., Mihura, J.L., 2010. Assessment of alexithymia with the Rorschach Comprehensive System: The Rorschach Alexithymia Scale (RAS). Journal of Personality Assessment 92, 128–136. Reise, S.P., 2012. The rediscovery of bifactor measurement models. Multivariate Behavioral Research 47, 667–696. Reise, S.P., Bonifay, W.E., Haviland, M.G., 2013. Scoring and modeling psychological measures in the presence of multidimensionality. Journal of Personality Assessment 95, 129–140. Reise, S.P., Moore, T.M., Haviland, M.G., 2010. Bifactor models and rotations: Exploring the extent to which multidimensional data yield univocal scale scores. Journal of Personality Assessment 92, 544–559. Reise, S.P., Oliver, C.J., 1994. Psychological implications of the psychopathy Q-sort. Journal of Personality Assessment 65, 300–312. Ruesch, J., 1948. The infantile personality. Psychosomatic Medicine 10, 134–144. Sifneos, P.E., 1967. Clinical observations on some patients suffering from a variety of psychosomatic diseases. Acta Medicina Psychosomatica 7, 1–10. Sifneos, P.E., 1973. The prevalence of ‘alexithymic’ characteristics in psychosomatic patients. Psychotherapy and Psychosomatics 22, 255–262. Sifneos, P.E., 1996. Alexithymia: Past and present. American Journal of Psychiatry 153, 137–142. Sifneos, P.E., 1983. Psychotherapies for psychosomatic and alexithymic patients. Psychotherapy and Psychosomatics 40, 66–73. Sifneos, P.E., 1987. Anhedonia and alexithymia: A potential correlation? In: Clark, D. C., Fawcett, J. (Eds.), Anhedonia and Affect Deficit States. New York, NY: PMA Publishing Corporation, pp. 199−127. Subic-Wrana, C., Bruder, S., Thomas, W., Lane, R.D., Kohle, K., 2005. Emotional awareness deficits in inpatients of a psychosomatic ward: A comparison of two different measures of alexithymia. Psychosomatic Medicine 67, 483–489. Taylor, G.J., 1984. Alexithymia: Concept, measurement, and implications for treatment. American Journal of Psychiatry 141, 725–732. Taylor, G.J., Bagby, R.M., 2012. The alexithymia personality dimension. In: Widiger, T.A. (Ed.), The Oxford Handbook of Personality Disorders. New York, NY: Oxford University Press, pp. 648–673. Taylor, G.J., Bagby, R.M., 2013a. Alexithymia and the five-factor model of personality. In: Widiger, T.A., Costa, P.T. (Eds.), Personality Disorders and the Five-Factor Model of Personality. Washington, DC: American Psychological Association, pp. 193–207. Taylor, G.J., Bagby, R.M., 2013b. Psychoanalysis and empirical research: The example of alexithymia. Journal of the American Psychoanalytic Association 61, 99–133. Taylor, G.J., Bagby, R.M., Luminet, O., 2000. Assessment of alexithymia: Self-report and observer measures. In: Bar-On, R., Parker, J.D.A. (Eds.), The Handbook of Emotional Intelligence: Theory, Development, Assessment, and Application at Home, School, and in the Workplace. San Francisco, CA: Jossey-Bass, pp. 301–319.
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Taylor, G.J., Bagby, R.M., Parker, J.D.A., 1997. Disorders of Affect Regulation: Alexithymia in Medical and Psychiatric Illness. Cambridge: Cambridge University Press. Taylor, G.J., Bagby, R.M., Parker, J.D.A., 2003. The 20-item Toronto Alexithymia Scale. IV. Reliability and factorial validity in different languages and cultures. Journal of Psychosomatic Research 55, 277–283. Van der Kolk, B.A., McFarlane, A.C., Weisaeth, L. (Eds.), 1996. Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, NY: The Guilford Press.
Vorst, H.C.M., Bermond, B., 2001. Validity and reliability of the Bermond− Vorst Alexithymia Questionnaire. Personality and Individual Differences 30, 413–434. Wurmser, L., 1974. Psychoanalytic considerations of the etiology of compulsive drug use. Journal of the American Psychoanalytic Association 22, 820–843.
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Glossary Anterior cingulate cortex Midline cortical structure involved in many processes, including cognition, emotion, pain, and attention. Bifactor model A factor model that specifies a general factor believed to influence all items and three or more orthogonal group factors that account for residual common variance. Classic psychosomatic diseases Seven medical conditions (e.g., peptic ulcer) thought in the 1950s and 1960s (but no longer) to be caused by stress or psychological factors. Emotional intelligence The ability to perceive, use, understand, and manage emotions.
History To characterize classic psychosomatic patients who could neither describe nor differentiate their feelings or elaborate their fantasies, psychiatrist Peter Sifneos coined the word ‘alexithymia’ for the set of cognitive–affective characteristics that he and his Harvard Medical School colleague, John Nemiah, had observed and systematically evaluated. Sifneos drew on Greek (a [lack], lexis [word], and thymos [emotion]) to name this cluster of features, which also included a preoccupation with the trivial aspects of external events and a proclivity to describe them in considerable and boring detail (Nemiah and Sifneos, 1970; Sifneos, 1973, 1967). Concurrently, but independently, Krystal (1968) observed these characteristics in patients who had experienced traumatic stress or were drug dependent (Krystal and Raskin, 1970; see also Krystal, 1988), as did Bruch (1973) in anorexia nervosa patients and Wurmser (1974) in narcotic-addicted patients. Clinical observations of alexithymia, although not yet named, date back to the 1940s. Alexithymic deficits, for example, were described in patients with classic psychosomatic diseases as well as in general psychiatric patients, and particularly in those responding poorly to psychoanalytic therapy (Ruesch, 1948; Maclean, 1949; Horney, 1952; Kelman, 1952). Moreover, the absence of fantasies and the externally oriented cognitive style that Sifneos and Nemiah observed already had been documented by Marty and de M’Uzan (1963) in physically-ill patients and labeled, la pensee operatoire (operative thinking). After years of clinical observation, however, the defining year for the alexithymia construct arrived in 1976 when it was selected as the main theme for the 11th European Conference on Psychosomatic Research in Heidelberg, Germany, and it was fully explicated by Nemiah et al. (1976). In this seminal publication, they described the characteristics of alexithymic individuals, including those many now assert as its core features (Taylor and Bagby, 2012, 2013a,b): (1) difficulties identifying and differentiating feelings, (2) difficulties
Encyclopedia of Mental Health, Volume 1
Epigenetics Genetic processes involving the interactions of genetic material and the environment that change the expression of a gene but do not alter the deoxyribonucleic acid (DNA) sequence. La pensee operatoire External (operative) thinking; thought content that is utilitarian and devoid of fantasy. Mentalization The ability to recognize one’s own mental states (e.g., beliefs, intentions, and desires) and those of others. Psychological mindedness One’s capacity to genuinely understand the interrelationships among thoughts, feelings, and actions of self and others. Q-sort method A person-versus variable-centered approach to personality assessment.
describing feelings, (3) impoverished fantasy lives, and (4) an externally oriented cognitive style (the latter two corresponding to la pensee operatoire). It is important to note, however, that individuals with alexithymic deficits can have outbursts of sadness or rage, which may seem to be at odds with the definition, but they have no understanding of these strong emotional expressions (Taylor et al., 1997). Primary versus secondary alexithymia was a distinction made many years ago, with primary alexithymia thought to reflect ‘structural or neurobiological defects’ and secondary (acquired) alexithymia seen as emerging from ‘developmental arrests or from a catastrophic environmental onslaught’ (Sifneos, 1987, p. 123; see also Sifneos, 1983), or a reaction to life-threatening illness or medical treatment (Freyberger, 1977; Lumley et al., 2007). As Taylor et al. (1997) have underscored, however, regardless of etiology, alexithymia is not ‘simply’ emotional non-expression in the face of situational stressors that clears when stress abates (see also Taylor and Bagby, 2012, 2013a,b); rather, alexithymic deficits are profound and enduring (Krystal, 1988; van der Kolk et al., 1996). Contemporary theory and research suggest that several factors – structural, functional, epigenetic, for example – can contribute to the development of alexithymia (Berthoz et al., 2011; Krystal, 1988; Taylor et al., 1997). By the early/mid-1980s, alexithymia’s definition (above) and its consequences (e.g., vulnerability to a variety of illnesses as well as poor treatment responses), summarized at the time by Taylor (1984) seemed at least somewhat clear based on clinical observations. The construct, nevertheless, needed empirical exploration and, as new information became available, refinement (Lesser and Lesser, 1983).
Modern Definitions and Measurement Jack Block, in his preface to Personality as an Affect-Processing System: Toward an Integrative Theory wrote, “… the field of
doi:10.1016/B978-0-12-397045-9.00227-5
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personality research continues inchoate… It is lively, conceptually multilingual, empirically prolific, contentious, ambitious, and unsatisfying.” (Block, 2002, p. xi). Such is an apt description of the present state of alexithymia research. Efforts to validate the alexithymia construct through research and measurement began in earnest in 1985. Although progress in both theory and measurement has occurred (Berthoz et al., 2011; Taylor and Bagby, 2012), various issues continue to spark. Self-report is the most common assessment method, for example, despite the availability of structured/semi-structured interviews and observer-rated measures, the clear and persistent recommendations to use multiple assessment methods (in general, see Funder, 1999; in alexithymia research, Taylor and Bagby, 2012), and doubts about whether individuals with alexithymic deficits are sufficiently equipped to rate their own deficits (Lane et al., 1999; Sifneos, 1996). In response to debates about measurement shortcomings, researchers have developed a variety of instruments, which are described along with item content/conceptual coverage in Table 1. Reviews of these are available (e.g., Lumley et al., 2007; Taylor and Bagby, 2012; Taylor et al., 1997, 2000) as studies of the interrelationships among measures (e.g., Berthoz et al., Table 1
2007; Dorard et al., 2008; Lumley et al., 2005; Meganck et al., 2011). Many alexithymia measures have been translated into several languages. All have ‘passed’ various, conventional psychometric tests and appear not to have the same limits of the earliest measurement attempts (Taylor et al., 1997). With occasional exceptions, the relationships among measures are as expected, given comparisons within and across methods.
Self-Report Scales The Twenty-item Toronto Alexithymia Scale (TAS-20; Bagby et al., 1994a,b), the third in the family of Toronto Alexithymia scales, is far and away the most popular measure. With a few exceptions, research supports the TAS-20’s three-factor structure (Parker et al., 2003; Taylor et al., 2003): difficulty identifying feelings, difficulty communicating feelings, and external thinking (external-thinking indirectly taps restricted imagination). Consistent with their view that alexithymia is dimensional (versus categorical), the test authors recommend using total TAS-20 scores as a continuous measure of alexithymia severity. Nevertheless, cut-off scores for ‘alexithymic’ and
Alexithymia measures
Instrument and source
Item content/conceptual coverage
Self-report Twenty-item Toronto Alexithymia Scale (TAS-20); Bagby et al., 1994a,b Bermond–Vorst Alexithymia Questionnaire (BVAQ); Vorst and Bermond, 2001
Difficulties identifying and differentiating feelings, difficulties describing feelings, an externally oriented cognitive style (and indirectly, reduced fantasy) Not emotional in emotion-provoking situations; limited fantasy and imagination; failures in identifying, analyzing, and verbalizing one's emotional states
Structured interview Toronto Structured Interview for Alexithymia (TSIA); Bagby et al., 2006a Diagnostic Criteria for Psychosomatic Research, Alexithymia (DCPR-A); Fava et al., 1995 Semi-structured interview Modified Beth Israel Hospital Psychosomatic Questionnaire (modified-BIQ); Bagby et al., 1994b California Q-set Alexithymia Prototype (CAQ-AP)b; Haviland and Reise, 1996
Observer report Observer Alexithymia Scale (OAS); Haviland et al., 2000c
Projective test Rorschach Alexithymia Scale (RAS); Porcelli and Mihura, 2010 Self-report/rater scored (indirect measure) Levels of Emotional Awareness Scale (LEAS); Lane et al., 1990 a
Difficulty identifying feelings, difficulty describing feelings to others, externally oriented thinking, and reduced fantasy/poor imagination Difficulties verbalizing and communicating emotional states, reduced fantasy, external thinking, physical reactions to strong emotions; outbursts of anger, crying, or joy (without understanding) Difficulties with the identification and verbal communication of feelings; poor imaginal activity, operatory thinking Difficulties experiencing and expressing emotion; poor interpersonal relationships; not warm or compassionate; lacking imagination and humor; neither introspective nor insightful; health worries; being literal, socially conforming, and utilitarian; anxiety and tension find outlet in bodily symptoms Lacking skill in interpersonal matters and relationships; poor stress tolerance, insight, and self-understanding; health concerns and physical problems; without imagination or humor; rigidity, excessive self-control Low awareness of affective states, poor fantasy, concrete/simplistic thinking; conventionality, social conformity; limited adaptive resources, difficulty managing interpersonal relationships Differentiation, specificity, and blending of emotions
Interviewers may be lay or professional, preferably trained in instrument administration and scoring, and familiar with the alexithymia construct. Lay or professional raters; interview not required if rater knows target well (may also be used as a self-report measure). c Lay or professional raters who know target well. b
Alexithymia ‘non-alexithymic’ have been established (Taylor et al., 1997), and they are used most effectively in time-consuming and expensive experimental and neuroimaging studies of cognition and affect (i.e., extreme groups method; see Berthoz et al., 2011; Grynberg et al., 2012; Moriguchi and Komaki, 2013). In response to the TAS-20’s multidimensional structure, researchers often calculate total and subscale scores and evaluate all relationships with external correlates, a practice that has presented interpretive challenges. Use of the TAS-20 in structural equation modeling (SEM/causal modeling) is inconsistent, too; sometimes all items are used, but other times items from only one or two subscales are used. Reise et al’s. (2013) bifactor modeling work supports the TAS-20 authors’ recommendation to use total TAS-20 scores (in general and in SEM) to represent alexithymia, given a relatively strong general factor, alexithymia. The Bermond–Vorst Alexithymia Questionnaire (BVAQ, Vorst and Bermond, 2001) was developed in response to what its authors believed to be incomplete conceptual coverage in the TAS-20 item pool. They appeared unpersuaded that external thinking adequately represented diminution of fantasy and suggested adding items to represent ‘reduced experiencing of emotional feelings.’ BVAQ data are used in two ways: (1) total scores as a continuous measure of alexithymia severity and (2) subscales to create ‘types” (combinations of high and low ‘cognitive’ and ‘affective’ components), although the latter practice has been met with some controversy (Berthoz et al., 2011; Taylor and Bagby, 2012; see also Bagby et al., 2009).
Interviews and Observer Ratings The Toronto Structured Interview for Alexithymia (TSIA; Bagby et al., 2006) was developed in response to repeated calls for multi-method alexithymia assessment, interviewer/observerrated measures, and direct measurement of reduced fantasy. It explicitly taps the aforementioned four defining features of alexithymia with 24 items rated on a 0–2 scale (six items for each feature with accompanying prompts/probes). Psychometric data are consistent across studies and support its use (Bagby et al., 2006; Caretti et al., 2011; Grabe et al., 2009). The Diagnostic Criteria for Psychosomatic Research, Alexithymia (DCPR-A; Fava et al., 1995) assesses 12 psychosocial syndromes clustered into five diagnostic rubrics, one of which is alexithymia. If individuals meet the established criteria for alexithymia, they are given the diagnosis. Used largely in European studies, its value in characterizing alexithymia in the medically ill, for example, is illustrated in Porcelli et al. (2013). The Modified Beth Israel Hospital Psychosomatic Questionnaire (modified-BIQ; Bagby et al., 1994b) is a revision of the original Beth Israel Hospital Psychosomatic Questionnaire (BIQ; Sifneos, 1973). The modified-BIQ is used only occasionally in contemporary research and mostly in psychometric studies (e.g., Bagby et al., 1994a,b; Haviland et al., 2002). The California Q-set Alexithymia Prototype (CAQ-AP; Haviland and Reise, 1996) was developed both to define and to measure alexithymia. The authors used the Q-sort method (Block, 2008) to construct the CAQ-AP. Thirteen alexithymia researchers – including seminal contributors to the field – described the personality characteristics of the prototypic
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‘alexithymic’ person with CAQ items to generate a consensus prototype. Conceptual coverage in the prototype is very good; in fact, John Nemiah wrote, “… of all the standardized measures, the CAQ-AP seems to me to provide the most accurate and complete description of alexithymia as it was first conceived of from clinical observation.” (J.C. Nemiah, personal communication, January 27, 1997). The Observer Alexithymia Scale (OAS; Haviland et al., 2000, 2001, 2002) was developed so that clinicians, family members, and acquaintances could provide alexithymia ratings (and ratings could be averaged across multiple informants). Item content, written in ordinary language, is from the CAQ-AP. Bifactor modeling has shown a strong general factor, alexithymia (Reise et al., 2010), and, thus, the authors recommend using total OAS scores to assess the construct.
Projective Technique The Rorschach Alexithymia Scale (RAS; Porcelli and Mihura, 2010) represents an effort to improve on Porcelli and Meyer’s (2002) original Rorschach-alexithymia work. The authors believe that the RAS is useful in clinical settings in which Rorschach testing is routine. Psychometric and applied work is needed, however, to support this expectation.
Measuring Emotional Awareness The Levels of Emotional Awareness Scale (LEAS; Lane et al., 1990) corresponds to Lane and Schwartz’s (1987) theory of emotional awareness (i.e., the ability to recognize and describe one’s emotions and those of others). The LEAS distinguishes between implicit/unconscious and explicit/conscious emotional awareness levels, and it has proven useful for conceptualizing and measuring alexithymia. Lane et al. (1999), for example, have proposed that alexithymia ‘represents a deficit in the conscious experience of emotion’ (p. 837) and, in fact, may be thought of as the emotional equivalent of blindsight or an impairment in knowing what one is feeling (more recently labeled affective agnosia). They contrast this with the more common alexithymia definition, a deficit in one’s ability to put feelings into words. Theoretical and empirical support comes from studies of the anterior cingulate cortex (i.e., its participation in processing emotional cues) (see Berthoz et al., 2011; Lane et al., 1998). The LEAS and the TAS-20 generally do not correlate well, but each has its place in alexithymia research (see recommended uses in Subic-Wrana, et al. (2005)).
Summary Overall, a fair amount of conceptual and item overlap (i.e., consensus) across the various direct alexithymia measures emerges, as shown in Table 1. Among the issues that remain unclear, however, are whether (1) the TAS-20 adequately taps reduced fantasy, (2) the ‘BVAQ factor,’ ‘reduced experiencing of emotional feelings,’ is justifiable/necessary (in other words, is it a defining feature), (3) it is appropriate to create alexithymia ‘types’ from BVAQ scores, and (4) social conformity is a defining versus an associated feature (see CAQ-AP and RAS item content). Finally, how best to use the TAS-20 and the
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LEAS in alexithymia research (and integrate findings across studies) is not entirely clear. Nowhere is this more apparent than in reviews of neuroimaging studies (e.g., Berthoz et al., 2011; Kano and Fukudo, 2013; Moriguchi and Komaki, 2013); drawing clear conclusions is difficult. Given the stated need for multi-method alexithymia assessments and the variety and demonstrated suitability of the available alexithymia instruments, it is unfortunate that researchers typically choose the convenience of a single self-report, the TAS-20 (and score it in a variety of ways). Moreover, in studies in which more than one measure is used, the objectives often are to determine the correlations between the measures (with the TAS-20 as a standard) and subsequently to decide whether the less popular measures are ‘valid’ (in other words, correlate moderately, at least, with the TAS-20) or ‘work’ as well as (or better than) the others. Clearly, using more than one instrument or method to assess a construct presents its own set of challenges (Funder, 1999), but advancing the field demands these challenges be faced. Although researchers recognize this (see calls for multi-method assessments in most articles’ discussion sections), they have been slow to make such investments.
Relationships with Other Constructs In the course of evaluating a less well-established construct, researchers often compare it with related constructs, as well as with the basic dimensions of personality. The relationship between alexithymia, emotional intelligence, and various traits involving access to and use of feelings (and recognizing those of others) – for example, psychological mindedness and mentalization – is well summarized in Bar-On and Parker (2000) and Taylor and Bagby (2012). This is a relatively large body of work, and the studies are theoretical and empirical (empirical work largely involves correlations between self-report scales). The general conclusion – albeit an oversimplification – is that alexithymia relates to (and to some extent, overlaps with) these various emotion recognition/use constructs, but that it is sufficiently distinct from each of them.
Alexithymia and the Basic Dimensions of Personality Researchers have studied alexithymia’s relationships to the basic dimensions of personality to evaluate alexithymia’s place in the study of personality, affects, and emotion (see also Block, 2002; Magai and McFadden, 1995). Notable examples include the Five-Factor Model (FFM, neuroticism, extraversion, openness, conscientiousness, and agreeableness; Costa and McCrae, 1992) and the Two-Factor Model (ego-control and ego-resilience; Block and Block, 1980). Taylor and Bagby (2012, 2013a), for example, have reviewed studies of the relationship between self-report TAS-20 and NEO Personality Inventory/NEO PI-R scores (Costa and McCrae, 1992) scores. In general, TAS-20 are associated with higher neuroticism broad-trait and facet scores and negatively with broad-trait and facet scores for extraversion and openness. These relationships are unsurprising, as alexithymic individuals correspondingly are seen as unhappy and lacking
emotional stability, not outgoing/social, and not curious, creative, or imaginative. Although a popular and useful framework, the FFM does not hold universal appeal nor does the reliance on self-report in personality assessment (Block, 1995). These misgivings, in part, prompted Haviland and Reise (1996) to develop the CAQ-AP and to compare it to the theoretical prototypes for ego-control (over- and under-control) and ego-resilience. Egocontrol is the expression/inhibition of impulse, and egoresilience is the capacity to contextually modify one’s level of ego-control in response to situational demands. As predicted, the CAQ-AP was correlated moderately with the overcontrol prototype and more strongly with the ego-brittle prototype. Prototypic overcontrolling and ego-brittle people, however, appear not to have the difficulties prototypic alexithymic individuals have in cognitively processing and attaching meaning to emotional stimuli or telling other people what they are feeling. Haviland and Reise (1996) believe that these data support the uniqueness of the alexithymia construct.
Alexithymia and Psychopathy Haviland et al. (2004) used the CAQ-AP to evaluate the relationship between alexithymia and psychopathy. To clarify the relationship between the two constructs, they compared theoretical prototypes (Block, 2008), the CAQ-AP with the CAQPsychopathy Prototype (CAQ-PP; Reise and Oliver, 1994). Prototypic alexithymic and psychopathic persons were found to be quite different. Traits that stand out for alexithymia are anxious, overcontrolled, submissive, boring, ethically consistent, and socially conforming, whereas those standing out for psychopathy are anxiety-free, undercontrolled, dominant, charming, deceitful, and nonconforming. Such clarity is elusive when one depends solely on correlating self-report scales (preceding and subsequent studies of alexithymia and psychopathy have yielded surprising, inconsistent, and difficult-tointerpret results).
Medical/Psychiatric Diagnoses and Treatment From the earliest clinical observations to present day reviews and empirical studies, the association between alexithymia and psychiatric/medical illnesses is quite consistent (Lumley, 2004; Lumley et al., 2007; Porcelli et al., 2013; Taylor and Bagby, 2012; Taylor et al., 1997). To this day, alexithymia is associated with, for example, anxiety, mood, and eating disorders; substance abuse and dependence; and chronic pain (including irritable bowel syndrome and fibromyalgia). Also associated with alexithymia are various medical disorders, notably hypertension and rheumatoid arthritis, and studies of alexithymia and autism spectrum disorders and traumatic brain injury are underway (Berthoz et al., 2013; Neumann et al., 2014). How alexithymic deficits are related to these illnesses is varied and complex (Kano and Fukudo, 2013; Lumley, 2004; Lumley et al., 1996, 2007; Taylor et al., 1997). Poor health among alexithymic individuals, for example, may be related to altered autonomic, endocrine, and immune activity. Moreover,
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individuals with severe alexithymic deficits attempt to regulate affects with drugs, alcohol, and compulsive behaviors and often make other damaging life choices (e.g., poor nutrition and exercise, and delays in treatment-seeking). As noted, alexithymic deficits also are associated with the failure to recover from various associated diseases. Unfortunately, evidence-based guidance about how best to address alexithymia in clinical settings is limited. Several clinician/researchers have offered suggestions (e.g., supportive vs. insightoriented therapy) (Krystal, 1979, 1988; Lumley, 2004; Taylor and Bagby, 2013b; Taylor et al., 1997). Outcome data are scarce, but some, at least, are encouraging (Lumley, 2004; Taylor and Bagby, 2012).
Conclusion Alexithymia is an intriguing topic, one that in 40 years has generated voluminous research. Although researchers and clinicians have made gains in conceptualizing and assessing alexithymia, considerable construct validity work remains. Debates about the definition and measurement of alexithymia continue, its etiology has not been established firmly, understanding of its links to physical disease (origins and treatment) is incomplete, and its neural correlates remain uncertain. Although these gaps are sobering, alexithymia work, nevertheless, holds promise. Thus, this entry ends with suggestions for creating more certainty and, perhaps, wider acceptance of the construct.
Recommended Research 1. Use more than one instrument to measure alexithymia (preferably one interviewer/observer measure) and find ways to integrate these complementary rather than competing approaches, rather than simply pit one against the other and choose the ‘best’ results. 2. Consider bifactor modeling (see Reise, 2012) as instruments are proposed, evaluated, and applied. Despite the demonstrated multidimensional structure of several alexithymia instruments, researchers’ main interest is to evaluate alexithymia. Thus, it is critical to know whether there is a strong general factor and also whether subscales provide any reliable information that is unique from the general factor. 3. Conduct studies of alexithymia and social conformity. It appears in several conceptualizations (see Table 1) but was dropped as a defining feature. 4. Use alexithymia as a mediator in studies of maltreatment/ trauma and health outcomes in cases, for example, where researchers might use other measures of emotion dysregulation or posttraumatic stress disorder (presence/absence or symptom severity). 5. Expand theoretical explorations by comparing the CAQ-AP to available CAQ prototypes, which can illustrate conceptual similarities and differences. Many have been developed for theoretical constructs and diagnostic labels (e.g., antisocial personality, narcissism, and depression), and others can be constructed.
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6. Finally, use alexithymia to represent emotion processing deficits when evaluating contemporary approaches to treating, for example, eating, substance use, and pain disorders.
See also: Adult Victims of Intimate Partner Violence: Mental Health Implications and Interventions. Alcohol Use Disorders. Behavioral Addiction. Child Maltreatment. Chronic Fatigue Syndrome: A Biopsychosocial Perspective. Eating Disorders. Emotional Intelligence. Empathy. Marijuana: Medical Applications, Recreational Use and Substance Abuse Disorders. Personality and Personality Development. Personality Assessment. Posttraumatic Stress Disorder. Psychopathy. Rape and Sexual Assault. Self-Regulation. Somatic Symptom Disorder. Substance Abuse: Drugs.
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