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Alexithymia and its Relationship to Hemispheric Specialization, Affect, and Creativity
Hemispheric Specialization
0193-953X/88 $0.00
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Alexithymia and its Relationship to Hemispheric Specialization, Affect, and Creativity P. E. Sifneos, MD .*
The title of this issue brings together, in an ingenious way, three aspects of brain function which at face value appear to have little in common with each other. For example, it could be argued that hemispheric specialization lies in the realm of neuroanatomy, neuropathology, neurology, and neurosurgery, whereas affect may have more to do with the work of the psychologist and the psychiatrist. Finally, creativity may be more in the domain of literature, philosophy, art, and science. Such territorial compartmentalizing, however, serves no purpose and has a tendency to miss the proverbial forest for the trees. In this article I should like to concentrate on affect in general, and alexithymia in particular, and to discuss briefly their connection with hemispheric specialization and creativity.
ALEXITHYMIA
Alexithymia, 13 from the Greek meaning "no words for emotions," is a specific kind of affect deficit that has important implications for medicine in general and psychiatry, psychology, and neurology in particular. It cannot be seen as a disease entity. Rather it was conceptualized in the 1960s as a major deficiency in the emotional life of human beings, and it was first observed during systematic clinical studies of patients suffering from a variety of psychosomatic diseases. 14 Alexithymia has aroused a great deal of interest because it has been associated with such pathologic conditions as psychosomatic illness, posttraumatic stress disorder, alcoholism, drug addiction, and sociopathic personality. In addition, although no figures have been offered to substantiate
*Professor of Psychiatry, Harvard Medical School; Associate Director, Department of Psychiatry, Beth Israel Hospital, Boston, Massachusetts
Psychiatric Clinics of North America-Vol. 11, No. 3, September 1988
287
288
P. E.
SIFNEOS
this statement, it seems to be widespread, and some authors have even ventured to call its deficiencies "the personality of our times. "7 What exactly is alexithymia? It is an inability to associate one's visual images, fantasies, and thoughts with a specific emotional state. One hears a suspicious noise during the night but starts thinking of food; one attacks someone but has no thoughts about what made him angry; one cannot experience joy by remembering some episode which had made him happy. In sum, one can think, can act, can talk, and can recognize emotions but cannot connect the thoughts with his emotions. One has no feelings yet has to live in a world full of talk about feelings. Under such circumstances, therefore, conflicts and difficulties are likely to appear. Is it possible that such individuals can exist? Before answering this question, I would like to define some of the terms which have already been used, in particular the words "affect," "emotion," and "feeling." Oxford Dictionary defines affect as "a mental disposition," emotions as "a mental feeling" (pain, desire, hope), and feeling as "a condition of being emotionally affected" (pleasurable or painful). 9 It appears then that one term is used to define the other. Looking first at affect, I would consider both biologic and psychologic components to be associated with it. The biologic side has to do with "visceral emotions," whereas the psychologic side deals with "feeling emotions," or simply "feelings." The anatomic sites for "visceral emotions" lie in various structures of the limbic system such as the amygdaloid complex and the hippocampus. The physiology of visceral emotions was established by Cannon as a central homeostatic mechanism that uses autonomic and endocrine circuits at times of emergency in the form of fight-flight patterns of behavior. From this description it should be concluded that all mammals experience "visceral emotion," which produces reflex-like responses and which has few if any cortical representations in the form of images, fantasies, and thoughts. (This may be obvious because certain mammals do not have the neocortical development necessary for the development of cognition.) In humans, on the other hand, owing to the enormous development of the neocortical structures, images, fantasies, and thoughts can be associated with "visceral emotions" and together constitute the psychologic component of affect- namely, "feeling emotions." This cognitive component, in terms of thalamic representations, is responsible for conscious awareness and is recognized in human beings as a "feeling." Neocortical activity then is a sine qua non of feelings . It utilizes appraisal and knowledge of the past to evaluate incoming sensations, as well as memory in order to label them as pleasant or unpleasant and to register them accordingly. Such labeling and registration involve understanding of the meaning of previous experiences, as well as language in order to express it. Difficulties then can b e expected if there is an interruption in the communications between limbic system activity and neocortical activity. Such an individual may experience visceral emotions and act in a reflex-like manner (fight-flight patterns); he may also be able to think but will not be able to have thoughts that are appropriate to the visceral emotion being experienced. Under such conditions he would be "alexithymic." In addition, if a visceral emotion takes
289
ALEXITHYMIA
place as a result of an interruption in communications between limbic system and neocortex, and if the incoming sensation is unable to reach the neocortex so as to arouse appropriate thoughts associated with it, it may be expressed via an autonomic and or endocrine route or by a reflex-like motor action. It is also possible that whatever cognitive activity is taking place at that moment would not be associated with the visceral emotions, would be inappropriate, and would have little to do with it. The resulting cognitive activity would take the form of a description of trivial and elaborate details relating to an environmental stimulus. This type of thinking has been described by the French psychoanalysts Marty and de M'Uzan and is called "pensee operatoire."7 To sum up, "affect" according to my definition is a product of both visceral emotions and feeling emotions. Alexithymia is an affect deficit because it points to a deficiency in the area of feeling emotions. The concept of alexithymia, as mentioned already, was developed after systematic clinical observations were made on a variety of patients suffering from medical illnesses. 15 At first, it was very difficult to believe that individuals could exist who had a great deal of trouble describing and expressing their feelings. Accepting the idea of such a condition was made easier when such patients were compared with others who had circumscribed neurotic problems and who, in contrast to the alexithymic ones, had a rich fantasy life as well as full access to their feelings. In addition to what has already been said about alexithymic individuals, it should be added that they also have a tendency to act impulsively, to assume rigid postures, to show a diminished capacity to dream and to cry, to speak in a monotone, and to find themselves confused whenever any one asks them questions relating to feelings. Although, as mentioned already, the first observations on alexithymia were made on patients suffering from a variety of psychosomatic diseases, it was also observed that many such patients were not alexithymic, whereas others who were alexithymic did not suffer from psychosomatic diseases. Over the last 25 years more and more observations have been made, and at present it is thought that alexithymia is widespread in both healthy and ill populations.
POSSIBLE ETIOLOGIC FACTORS What, then, are the factors that may be responsible for this deficiency in the area of feelings, which is similar to the deficiency of Korsakoff patients in the area of memory? One may conceptualize five possible etiologies for alexithymia. First, a structural neuroanatomic defect or a neurobiologic deficiency in the form of biochemical or physiologic abnormalities, due to hereditary factors, which interrupts the communication between limbic system and neocortex, may account for the presence of the alexithymic characteristics. These biologic defects have been considered a possible etiology of what has been termed "primary alexithymia". In addition, the role played by the cerebral hemispheres and hemispheric specialization seem to play a vital role in primary alexithymia. I am referring, of
290
P. E.
SIFNEOS
course, to the exciting innovative work on commissurotomy and hemisphericity which has been delt with extensively in this issue. 4 Since alexithymia involves, for example, an inability to connect images, fantasies, and thoughts with visceral emotions and to use appropriate language to express feelings, in a right-handed person, the left cerebral hemisphere, which involves the use of words and their articulation, is of course intimately associated with this process. In addition, however, an interruption of input from the right hemisphere may be just as important, because the right hemisphere plays a major role in modulating an affective component and in giving to language a special coloring, intonation, melody, and cadence, which are referred to collectively as "prosody." 10 Furthermore, recent investigations have suggested the existence of dominant functional-anatomic organization components of language and behavior and have emphasized the important role of the right hemisphere in modulating emotions. 11 In addition, two limbic cortical connections seem to exist, one involved with surveillance, attention, and arousal, and the other associated with stimulus identification, learning, and emotional response. 2 Finally, patients with right-hemispheric damage cannot assess emotional priorities and have difficulties in emotional communication in the form of "aprosody. " 12 It should be clear from this discussion that hemispheric specialization has a great deal to do with affect in general and alexithymia in particular. "Secondary alexithymia," on the other hand, may be associated with the other four possible etiologic factors. For example, a massive psychologic trauma occurring at a critical period of infant development may not only influence the verbal expression of feelings but also may have lasting effect on the whole way in which feelings are dealt with, that is, alexithymia. Another possibility has to do with the occurrence of a major traumatic environmental assault on an adult, who may have learned how to deal with feelings but who has to use massive regression as a way of adjusting to or escaping from the trauma and as a result experiences a partial or total numbing or a constriction of his feelings. Concentration camps and catastrophic war experiences have been implicated in causing reactions of apathy, numbing, and avoidance of feelings as ways of adjusting to the hostile environments. If such individuals manage to survive, they attribute their survival to their ability to avoid thinking about their feelings, and therefore they are very reluctant to give up this defense strategy. Finally sociocultural as well as psychodynamic factors such as an excessive use of defense mechanisms like repression, denial, and regression may lead to secondary alexithymia. It should be evident that alexithymia is the exact opposite of creativity. A creative person must utilize in full the capabilities of both cerebral hemispheres. A creative person must be original, imaginative, sensitive, able to discover hidden connections, to tolerate paradoxical thoughts, to use intuition, and have the capability to synthesize opposing and unrelated experiences into a meaningful whole. A creative person must theorize, invent, open his or her mind to incoming sensations, absorb new ways of looking at complexity, and devise novel ways to resolve varying and contradictory viewpoints. By mixing all these factors together a creative person can pro-
291
ALEXITHYMIA
duce new ideas and new theories and can use original language to express them. Such a person can create vast and exciting new worlds. Alexithymic individuals may be intelligent, but, as we have seen, they either lack feelings or they use their intelligence to avoid them, because they sense that they have deficiencies and difficulties in the affective area. They are usually tense, anhedonic, rigid, repetitive, and action-oriented. In the final analysis, they become dull and boring to those who come in contact with them. It seems, then, that by studying affect deficiencies in general and alexithymia in particular we can learn a great deal both about hemispheric specialization and about creativity. One last word should be said about the kind of help which might be offered to alexithymic individuals. Various approaches have been used, but there is general consensus that supportive psychotherapeutic interventions, utilizing empathic understanding of the alexithymic patients' conflicts with the external world, which result from their defects in the area of feelings, are helpful, particularly if used in conjunction with psychotropic medications. Such an approach seems best suited for individuals suffering from primary alexithymic difficulties. On the other hand, a variety of modified psychodynamic 16 interventions that may offer some help to individuals with secondary alexithymia are contraindicated for primary alexithymics because they may actually do more harm than good. For secondary alexithymics, group therapy using guided educational approaches and concrete visual feedback has been advocated by Ford and Long3 and Apfel-Savitz et al. 1 Ingenious innovative modifications of psychodynamic techniques are also used by Krystal, who encourages and educates patients to challenge, to cultivate as well as to tolerate, to manage, and finally to learn to verbalize their feelings. 5 · 6 Finally, for the roughly 20 per cent of patients whose alexithymic difficulties may be due to excessive utilization of denial and repression, psychoanalytically oriented psychotherapy or psychoanalysis as recommended by Stephanos, 17 McDougal, 8 and others may be tried and may offer some hope. The time has come to give up the rigid and obsessive concentration on narrow psychiatric nosologies and to move more into the investigation of broad psychopathologic phenomena such as affects, anxiety, depression, language, and cognition, to mention only a few, which cut across diagnostic entities and which can be studied biochemically, physiologically, neurologically, and psychodynamically. We must try to bridge the gaps separating medical specialties such as psychiatry, neurology, neurobiology, and neurosurgery and to avoid the use of such cliches as "functional" versus "organic" and "biologic" versus "psychologic." The editors of this publication have made an effort in this direction. It is hoped that others will be stimulated to do the same, so that such an integrative approach may become a dominant aspect of scientific and clinical investigation during the decade of the 1990s. SUMMARY
This article attempts to demonstrate the relations of alexithymia (no words for emotions) to hemispheric specialization and affect. In addition, it
292
P. E.
SIFNEOS
also points to alexithymia as a deficiency in the area of human feelings, and as such of being the opposite of creativity. The terms "affect," "emotion," and "feeling" are defined, and possible etiologic factors of the phenomenon of alexithymia are discussed, with special reference to primary and secondary alexithymia. The article concludes with a presentation of the kinds of therapeutic interventions that might be offered to alexithymic individuals, as well as with an appeal for an integration of scientific and clinical investigations.
REFERENCES l. Apfel-Savitz R, Silverman D, Bennett Ml, Group psychotherapy of patients with somatic illnesses and alexithymia. Psychother Psychosom 28:323-329, 1977 2. Bear D: Hemispheric specialization and the neurology of emotions . Arch Neural 40:195203, 1983 3. Ford CV, Long KD: Group psychotherapy for somatizing patients. Psychother Psychosom 28:294-304, 1977 4. Hoppe KE, Bogen SE: Alexithym ia in twelve commissurotomized patients. Psychother Psychosom 28:148-156, 1977 5. Krystal H: Adolescence and the tendencies to develop substance dependence. Psychoanal 2(4):581-618, 1982 6. Krystal H: Alexithymia and effectiveness of psychological treatment. Unpublished communication 7. Marty P, de M'Uzan DC: L'Investigation psychosomatique. Paris, Presses Universitaires, 1963 8. McDougal J: The psychosoma and the psychoanalytic process. Int Rev Psychoanal 1:437, 1974 9. Oxford Universal Dictionary. Oxford, Clarendon Press, 1955 10. Ross ED, Mesulam MM: Dominant language functions of right hemisphere? Arch Neural 36:144-149, 1979 11. Ross ED, Rush AJ: Diagnosis and neuroanatomical correlates of depression in braindamaged patients. Arch Neural 38:1344-1355, 1981 12. Ross ED: The aprosodias. Arch Neurol 38:561-570, 1981 13. Sifneos PE, Apfel-Savitz R, Frankel FH: The phenomenon of alexithymia. Psychother Psychosom 28:46-57, 1977 14. Sifneos PE: The prevalence of alexithymic characteristics in psychosomatic patients. Psychother Psychosom 22:255-263, 1973 15. Sifneos PE: Clinical observations on some patients suffering from a variety of psychosomatic diseases. In Antonelli : Proceedings of the 7th European Conference on Psychosomatic Research, Rome 1967. Acta Med Psychosom 1:1-10, 1967 16. Sifneos PE : Psychotherapies for psychosomatic and alexithymic patients. Psychother Psychosom 40:66-73, 1983 17. Stephanos SA: Concept of analytical treatment for patients with psychosomatic disorders. Psychother Psychosom 20: 178-187, 1972
Harvard Medical School Beth Israel Hospital Department of Psychiatry 330 Brookline Avenue Boston, Massachusetts 02215
0193-953X/88 $0.00
+
20
Alexithymia and its Relationship to Hemispheric Specialization, Affect, and Creativity P. E. Sifneos, MD .*
The title of this issue brings together, in an ingenious way, three aspects of brain function which at face value appear to have little in common with each other. For example, it could be argued that hemispheric specialization lies in the realm of neuroanatomy, neuropathology, neurology, and neurosurgery, whereas affect may have more to do with the work of the psychologist and the psychiatrist. Finally, creativity may be more in the domain of literature, philosophy, art, and science. Such territorial compartmentalizing, however, serves no purpose and has a tendency to miss the proverbial forest for the trees. In this article I should like to concentrate on affect in general, and alexithymia in particular, and to discuss briefly their connection with hemispheric specialization and creativity.
ALEXITHYMIA
Alexithymia, 13 from the Greek meaning "no words for emotions," is a specific kind of affect deficit that has important implications for medicine in general and psychiatry, psychology, and neurology in particular. It cannot be seen as a disease entity. Rather it was conceptualized in the 1960s as a major deficiency in the emotional life of human beings, and it was first observed during systematic clinical studies of patients suffering from a variety of psychosomatic diseases. 14 Alexithymia has aroused a great deal of interest because it has been associated with such pathologic conditions as psychosomatic illness, posttraumatic stress disorder, alcoholism, drug addiction, and sociopathic personality. In addition, although no figures have been offered to substantiate
*Professor of Psychiatry, Harvard Medical School; Associate Director, Department of Psychiatry, Beth Israel Hospital, Boston, Massachusetts
Psychiatric Clinics of North America-Vol. 11, No. 3, September 1988
287
288
P. E.
SIFNEOS
this statement, it seems to be widespread, and some authors have even ventured to call its deficiencies "the personality of our times. "7 What exactly is alexithymia? It is an inability to associate one's visual images, fantasies, and thoughts with a specific emotional state. One hears a suspicious noise during the night but starts thinking of food; one attacks someone but has no thoughts about what made him angry; one cannot experience joy by remembering some episode which had made him happy. In sum, one can think, can act, can talk, and can recognize emotions but cannot connect the thoughts with his emotions. One has no feelings yet has to live in a world full of talk about feelings. Under such circumstances, therefore, conflicts and difficulties are likely to appear. Is it possible that such individuals can exist? Before answering this question, I would like to define some of the terms which have already been used, in particular the words "affect," "emotion," and "feeling." Oxford Dictionary defines affect as "a mental disposition," emotions as "a mental feeling" (pain, desire, hope), and feeling as "a condition of being emotionally affected" (pleasurable or painful). 9 It appears then that one term is used to define the other. Looking first at affect, I would consider both biologic and psychologic components to be associated with it. The biologic side has to do with "visceral emotions," whereas the psychologic side deals with "feeling emotions," or simply "feelings." The anatomic sites for "visceral emotions" lie in various structures of the limbic system such as the amygdaloid complex and the hippocampus. The physiology of visceral emotions was established by Cannon as a central homeostatic mechanism that uses autonomic and endocrine circuits at times of emergency in the form of fight-flight patterns of behavior. From this description it should be concluded that all mammals experience "visceral emotion," which produces reflex-like responses and which has few if any cortical representations in the form of images, fantasies, and thoughts. (This may be obvious because certain mammals do not have the neocortical development necessary for the development of cognition.) In humans, on the other hand, owing to the enormous development of the neocortical structures, images, fantasies, and thoughts can be associated with "visceral emotions" and together constitute the psychologic component of affect- namely, "feeling emotions." This cognitive component, in terms of thalamic representations, is responsible for conscious awareness and is recognized in human beings as a "feeling." Neocortical activity then is a sine qua non of feelings . It utilizes appraisal and knowledge of the past to evaluate incoming sensations, as well as memory in order to label them as pleasant or unpleasant and to register them accordingly. Such labeling and registration involve understanding of the meaning of previous experiences, as well as language in order to express it. Difficulties then can b e expected if there is an interruption in the communications between limbic system activity and neocortical activity. Such an individual may experience visceral emotions and act in a reflex-like manner (fight-flight patterns); he may also be able to think but will not be able to have thoughts that are appropriate to the visceral emotion being experienced. Under such conditions he would be "alexithymic." In addition, if a visceral emotion takes
289
ALEXITHYMIA
place as a result of an interruption in communications between limbic system and neocortex, and if the incoming sensation is unable to reach the neocortex so as to arouse appropriate thoughts associated with it, it may be expressed via an autonomic and or endocrine route or by a reflex-like motor action. It is also possible that whatever cognitive activity is taking place at that moment would not be associated with the visceral emotions, would be inappropriate, and would have little to do with it. The resulting cognitive activity would take the form of a description of trivial and elaborate details relating to an environmental stimulus. This type of thinking has been described by the French psychoanalysts Marty and de M'Uzan and is called "pensee operatoire."7 To sum up, "affect" according to my definition is a product of both visceral emotions and feeling emotions. Alexithymia is an affect deficit because it points to a deficiency in the area of feeling emotions. The concept of alexithymia, as mentioned already, was developed after systematic clinical observations were made on a variety of patients suffering from medical illnesses. 15 At first, it was very difficult to believe that individuals could exist who had a great deal of trouble describing and expressing their feelings. Accepting the idea of such a condition was made easier when such patients were compared with others who had circumscribed neurotic problems and who, in contrast to the alexithymic ones, had a rich fantasy life as well as full access to their feelings. In addition to what has already been said about alexithymic individuals, it should be added that they also have a tendency to act impulsively, to assume rigid postures, to show a diminished capacity to dream and to cry, to speak in a monotone, and to find themselves confused whenever any one asks them questions relating to feelings. Although, as mentioned already, the first observations on alexithymia were made on patients suffering from a variety of psychosomatic diseases, it was also observed that many such patients were not alexithymic, whereas others who were alexithymic did not suffer from psychosomatic diseases. Over the last 25 years more and more observations have been made, and at present it is thought that alexithymia is widespread in both healthy and ill populations.
POSSIBLE ETIOLOGIC FACTORS What, then, are the factors that may be responsible for this deficiency in the area of feelings, which is similar to the deficiency of Korsakoff patients in the area of memory? One may conceptualize five possible etiologies for alexithymia. First, a structural neuroanatomic defect or a neurobiologic deficiency in the form of biochemical or physiologic abnormalities, due to hereditary factors, which interrupts the communication between limbic system and neocortex, may account for the presence of the alexithymic characteristics. These biologic defects have been considered a possible etiology of what has been termed "primary alexithymia". In addition, the role played by the cerebral hemispheres and hemispheric specialization seem to play a vital role in primary alexithymia. I am referring, of
290
P. E.
SIFNEOS
course, to the exciting innovative work on commissurotomy and hemisphericity which has been delt with extensively in this issue. 4 Since alexithymia involves, for example, an inability to connect images, fantasies, and thoughts with visceral emotions and to use appropriate language to express feelings, in a right-handed person, the left cerebral hemisphere, which involves the use of words and their articulation, is of course intimately associated with this process. In addition, however, an interruption of input from the right hemisphere may be just as important, because the right hemisphere plays a major role in modulating an affective component and in giving to language a special coloring, intonation, melody, and cadence, which are referred to collectively as "prosody." 10 Furthermore, recent investigations have suggested the existence of dominant functional-anatomic organization components of language and behavior and have emphasized the important role of the right hemisphere in modulating emotions. 11 In addition, two limbic cortical connections seem to exist, one involved with surveillance, attention, and arousal, and the other associated with stimulus identification, learning, and emotional response. 2 Finally, patients with right-hemispheric damage cannot assess emotional priorities and have difficulties in emotional communication in the form of "aprosody. " 12 It should be clear from this discussion that hemispheric specialization has a great deal to do with affect in general and alexithymia in particular. "Secondary alexithymia," on the other hand, may be associated with the other four possible etiologic factors. For example, a massive psychologic trauma occurring at a critical period of infant development may not only influence the verbal expression of feelings but also may have lasting effect on the whole way in which feelings are dealt with, that is, alexithymia. Another possibility has to do with the occurrence of a major traumatic environmental assault on an adult, who may have learned how to deal with feelings but who has to use massive regression as a way of adjusting to or escaping from the trauma and as a result experiences a partial or total numbing or a constriction of his feelings. Concentration camps and catastrophic war experiences have been implicated in causing reactions of apathy, numbing, and avoidance of feelings as ways of adjusting to the hostile environments. If such individuals manage to survive, they attribute their survival to their ability to avoid thinking about their feelings, and therefore they are very reluctant to give up this defense strategy. Finally sociocultural as well as psychodynamic factors such as an excessive use of defense mechanisms like repression, denial, and regression may lead to secondary alexithymia. It should be evident that alexithymia is the exact opposite of creativity. A creative person must utilize in full the capabilities of both cerebral hemispheres. A creative person must be original, imaginative, sensitive, able to discover hidden connections, to tolerate paradoxical thoughts, to use intuition, and have the capability to synthesize opposing and unrelated experiences into a meaningful whole. A creative person must theorize, invent, open his or her mind to incoming sensations, absorb new ways of looking at complexity, and devise novel ways to resolve varying and contradictory viewpoints. By mixing all these factors together a creative person can pro-
291
ALEXITHYMIA
duce new ideas and new theories and can use original language to express them. Such a person can create vast and exciting new worlds. Alexithymic individuals may be intelligent, but, as we have seen, they either lack feelings or they use their intelligence to avoid them, because they sense that they have deficiencies and difficulties in the affective area. They are usually tense, anhedonic, rigid, repetitive, and action-oriented. In the final analysis, they become dull and boring to those who come in contact with them. It seems, then, that by studying affect deficiencies in general and alexithymia in particular we can learn a great deal both about hemispheric specialization and about creativity. One last word should be said about the kind of help which might be offered to alexithymic individuals. Various approaches have been used, but there is general consensus that supportive psychotherapeutic interventions, utilizing empathic understanding of the alexithymic patients' conflicts with the external world, which result from their defects in the area of feelings, are helpful, particularly if used in conjunction with psychotropic medications. Such an approach seems best suited for individuals suffering from primary alexithymic difficulties. On the other hand, a variety of modified psychodynamic 16 interventions that may offer some help to individuals with secondary alexithymia are contraindicated for primary alexithymics because they may actually do more harm than good. For secondary alexithymics, group therapy using guided educational approaches and concrete visual feedback has been advocated by Ford and Long3 and Apfel-Savitz et al. 1 Ingenious innovative modifications of psychodynamic techniques are also used by Krystal, who encourages and educates patients to challenge, to cultivate as well as to tolerate, to manage, and finally to learn to verbalize their feelings. 5 · 6 Finally, for the roughly 20 per cent of patients whose alexithymic difficulties may be due to excessive utilization of denial and repression, psychoanalytically oriented psychotherapy or psychoanalysis as recommended by Stephanos, 17 McDougal, 8 and others may be tried and may offer some hope. The time has come to give up the rigid and obsessive concentration on narrow psychiatric nosologies and to move more into the investigation of broad psychopathologic phenomena such as affects, anxiety, depression, language, and cognition, to mention only a few, which cut across diagnostic entities and which can be studied biochemically, physiologically, neurologically, and psychodynamically. We must try to bridge the gaps separating medical specialties such as psychiatry, neurology, neurobiology, and neurosurgery and to avoid the use of such cliches as "functional" versus "organic" and "biologic" versus "psychologic." The editors of this publication have made an effort in this direction. It is hoped that others will be stimulated to do the same, so that such an integrative approach may become a dominant aspect of scientific and clinical investigation during the decade of the 1990s. SUMMARY
This article attempts to demonstrate the relations of alexithymia (no words for emotions) to hemispheric specialization and affect. In addition, it
292
P. E.
SIFNEOS
also points to alexithymia as a deficiency in the area of human feelings, and as such of being the opposite of creativity. The terms "affect," "emotion," and "feeling" are defined, and possible etiologic factors of the phenomenon of alexithymia are discussed, with special reference to primary and secondary alexithymia. The article concludes with a presentation of the kinds of therapeutic interventions that might be offered to alexithymic individuals, as well as with an appeal for an integration of scientific and clinical investigations.
REFERENCES l. Apfel-Savitz R, Silverman D, Bennett Ml, Group psychotherapy of patients with somatic illnesses and alexithymia. Psychother Psychosom 28:323-329, 1977 2. Bear D: Hemispheric specialization and the neurology of emotions . Arch Neural 40:195203, 1983 3. Ford CV, Long KD: Group psychotherapy for somatizing patients. Psychother Psychosom 28:294-304, 1977 4. Hoppe KE, Bogen SE: Alexithym ia in twelve commissurotomized patients. Psychother Psychosom 28:148-156, 1977 5. Krystal H: Adolescence and the tendencies to develop substance dependence. Psychoanal 2(4):581-618, 1982 6. Krystal H: Alexithymia and effectiveness of psychological treatment. Unpublished communication 7. Marty P, de M'Uzan DC: L'Investigation psychosomatique. Paris, Presses Universitaires, 1963 8. McDougal J: The psychosoma and the psychoanalytic process. Int Rev Psychoanal 1:437, 1974 9. Oxford Universal Dictionary. Oxford, Clarendon Press, 1955 10. Ross ED, Mesulam MM: Dominant language functions of right hemisphere? Arch Neural 36:144-149, 1979 11. Ross ED, Rush AJ: Diagnosis and neuroanatomical correlates of depression in braindamaged patients. Arch Neural 38:1344-1355, 1981 12. Ross ED: The aprosodias. Arch Neurol 38:561-570, 1981 13. Sifneos PE, Apfel-Savitz R, Frankel FH: The phenomenon of alexithymia. Psychother Psychosom 28:46-57, 1977 14. Sifneos PE: The prevalence of alexithymic characteristics in psychosomatic patients. Psychother Psychosom 22:255-263, 1973 15. Sifneos PE: Clinical observations on some patients suffering from a variety of psychosomatic diseases. In Antonelli : Proceedings of the 7th European Conference on Psychosomatic Research, Rome 1967. Acta Med Psychosom 1:1-10, 1967 16. Sifneos PE : Psychotherapies for psychosomatic and alexithymic patients. Psychother Psychosom 40:66-73, 1983 17. Stephanos SA: Concept of analytical treatment for patients with psychosomatic disorders. Psychother Psychosom 20: 178-187, 1972
Harvard Medical School Beth Israel Hospital Department of Psychiatry 330 Brookline Avenue Boston, Massachusetts 02215