Sunday, March 4, 2007

Asperger's and Alexithymia

“We now have a psychological term, alexithymia, to describe another characteristic associated with Asperger’s syndrome… Clinical experience and research have confirmed that alexithymia can be recognized in the profile of abilities of people with Asperger’s syndrome.” [Tony Attwood]

Ongoing research has revealed a significant overlap between alexithymia [definition] and autistic spectrum disorders (ASD's). Two recent studies25 suggest that individuals with ASD exhibit a higher degree of alexithymia than matched control participants, with 85% of the participants with ASD showing slight or severe alexithymic impairment. This raises the important questions for future research regarding how to explain the high co-morbidity of alexithymia and ASD, and from a clinical perspective the finding suggests that a diagnosis of ASD should be considered in patients with alexithymia.

[This] overlap may be applicable for Asperger's syndrome, which has similarities with alexithymic behaviour that have long been recognized. Every well known AS measure reflects the centrality of alexithymic phenomena in its diagnostic criteria: e.g. Lack of social or emotional reciprocity (DSM-IV), Impaired or deviant response to other people's emotions (ICD-10), Difficulty sensing feelings of others (Szatmari criteria), Difficulties expressing themselves, especially when talking about emotions (NAS definition), Emotionally inappropriate behaviour… Impairment of comprehension (Gillberg criteria).

Like all alexithymic persons, AS individuals have difficulty understanding their own and others' emotional arousal along with problems expressing feelings with verbal and nonverbal behaviour or in reading that of others, which correlate with the alexithymic subtraits: (a) difficulty identifying feelings and distinguishing between feelings and bodily sensations of emotional arousal, and (b) difficulty describing feelings to other people. In AS there is also a limited imagination, an absence of symbolic thinking, and a preoccupation with factual information which traits correlate with the alexithymic: (c) constricted imaginal processes, as evidenced by a paucity of fantasies, and; (d) a stimulus-bound, externally oriented cognitive style. The syndromes also share a propensity for psychosomatic disorders and hypochondriacal features26

Similarities noted, there are further distinguishing traits marking Asperger’s syndrome such as the tendency toward mild autistic behaviours like 'stereotyped and repetitive motor mannerisms such as hand or finger flapping or twisting, or complex whole-body movements'27 which are not features of simple alexithymia, and secondly, whilst AS individuals are with few exceptions alexithymic they have added difficulties in reading the objective, non-emotional intentions of others' minds. This mind-reading or ‘Theory of Mind’ (ToM) is the ability individuals may or may not possess for understanding and interpreting the mindset of another person, where the observer predicts the thoughts of the target individual by placing him or herself in their position and simulating the actions or beliefs of the target individual. Whilst a lack of ToM is central to Asperger’s syndrome, a recent study has shown that this is not a deficiency integral to uncomplicated alexithymia.28 This study selected forty-five high alexithymic subjects to undertake a 'false belief task' which involved a picture-sequencing task of four cartoon-style cards focussing on beliefs of an objective kind that did not require the identification of an emotional component. The task gauged their ability to read the thoughts of others based on the available cues. Alexithymic subjects were able to correctly complete the task, sometimes performing better than samples from a group of non-alexithymic subjects who completed the task, leading to the conclusion that alexithymic individuals possessed a Theory of Mind. At present ToM measures do not gauge ability or inability to recognise discrete emotions, meaning it does not adequately distinguish between alexithymic and non-alexithymic traits; its aim is purely to measure an individual’s ability to read the objective thought patterns of other people.

Individuals with uncomplicated or ‘simple’ alexithymia are more socially adaptive than AS individuals principally because they have a Theory of Mind allowing a degree of social competence, but problems arise when they are faced with situations where intimacy is required. Alexithymics may develop the ability to interpret and navigate the social world by applying logical rules about the beliefs and behaviours of other people but cannot articulate the emotional nuances which are intertwined with these interpersonal beliefs, i.e. they are able to anticipate and interact with others so as to form functional, but not feelings-based intimacies.

As well as mild autistic behaviours and mind-blindness, alexithymia constitutes a core factor of Asperger's syndrome as it is presently conceived. While this has not been strongly recognised in the past, it is becoming increasingly clear that the alexithymia construct is the most accurate, scientifically validated measure for gauging the emotional ‘differences’ inherent to Asperger’s syndrome. As remarked by a leading AS researcher Tony Atwood: “We now have a psychological term, alexithymia, to describe another characteristic associated with Asperger’s syndrome, namely someone who has an impaired ability to identify and describe feeling states. Clinical experience and research have confirmed that alexithymia can be recognized in the profile of abilities of people with Asperger’s syndrome…”29

[Excerpted from 'Blocked Imagination~ Emptied Speech' – by Jason Thompson]


25. E. Hill, S. Berthoz, & U. Frith, 'Journal of Autism and Developmental Disorders' 34, 229-235 (2004) and; S. Berthoz, & E. Hill, 'European Psychiatry' 20, 291-298 (2005)

26. Michael Fitzgerald & Guy Molyneux- The overlap between Alexithymia and Asperger's Syndrome. Letter to the Editor; American Journal of Psychiatry 161, 2134-2135, (2004)

27. Diagnostic and Statistical Manual (DSM-IV) criteria 299.80 Asperger's Disorder- (B: 4)

28. Colin A. Wastell, Alan J. Taylor- Alexithymic mentalising: Theory of mind and social adaptation. Social Behavior and Personality, (2002)

29. Tony Attwood- The Complete Guide to Asperger's Syndrome (2005)

For a slightly improved, updated version of the above article, see the book below:

Emotionally Dumb: An Overview of Alexithymia (1) - Kindle Edition - Kindle Book (July 16, 2009) by Jason Thompson
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Alexithymia and Asperger syndrome
[Alexitimia y síndrome de Asperger – translated from Spanish].

Isabel Paula-Pérez, Juan Martos-Pérez, María Llorente-Comí.

[Rev Neurol 2010, 50 (Suppl. 3): S85-S90]

[PMID: 20200852 - Presentation - Publication Date: 03/03/2010]

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Introduction: The study starts with the hypothesis that the difficulty in identifying and describing emotions and feelings, and distinguishing the feelings of bodily sensations that accompany them, are a common denominator in the constructs of alexithymia and Asperger syndrome (AS).

Patients and methods: The study evaluates the levels of alexithymia in nine males with AS.

Apparatus and procedure: We used the following scales and questionnaires (with the sample we also used other instruments not included in current study): Toronto Alexithymia Scale (TAS-20) The TAS was developed by Bagby et al [6] has two validations: the Moral de la Rubia and Retana [7] and Martinez-Sanchez [8]. Alexithymia scale for observers (OAS) has been used in various publications, for example, Haviland et al [10] and was translated directly from its original source. Online Alexithymia Questionnaire (OAQ-G2) The OAQ-G2 was developed in 2005 by Thompson [9] in response to perceived limitations in other existing alexithymia questionnaires, and was translated by A JJ Ordinas and R. Nogués.

Results: With the TAS-20, 5 subjects (55%) obtained a score indicating the presence of alexithymia, 1 subject (11%) obtained a score that suggests possible alexithymia, and in 3 cases (34%) the score indicates absence of alexithymia. That is, with this instrument, two thirds of subjects had alexithymia. With the OAQ-G2, 3 subjects (34%) obtained a score indicating a clear presence of alexithymia, 4 patients (44%) obtained a score that suggests possible alexithymia, and in 2 subjects (22%) the score indicates absence of alexithymia. With this instrument and adding the first two groups of people, three-quarters of the subjects had or may have alexithymia.

Discussion: The research reveals an overlap between alexithymia and AS. The data obtained in the sample agree with those obtained by Hill et al [12], who found that 85% of people with AS showed a moderate or severe alexithymia. The global analysis of data prompts a differentiation of results according to whether the source of information is the subject itself with AS (TAS-20 and OAQ-G2) or if the source is a relative who lives with the person with AS (OAS). In the first case, the data are significant but not conclusive: two thirds of patients with AS have or may alexithymia, according to the TAS-20 and three quarters have or may alexithymia, according to the OAQ-G2. However, when it comes to assessing the levels of alexithymia by the family, the data are crucial, doubling the score in the neurotypical population.

The study results are very significant when it comes to assessing the levels of alexithymia in patients with AS by people living with them, their families. These are those who experience daily the impact it has on their interpersonal relationships of family: little warmth in the relationship, difficulty feeling compassion, little tenderness, stiffness in everyday life, confusion to stress, frustration in dealing with uncertainty, little sense of humor, etc. The prospective research invites the question of how to explain the high comorbidity between alexithymia and AS. Is alexithymia a neuroanatomical structural consequence or is the result of a neurobiological impairment, or is it rather an idiosyncratic personality trait of individuals with AS? If so, would alexithymia therefore be a useful diagnostic criterion for the AS? Not surprisingly, the diagnostic criteria covers various aspects of alexithymia: 'lack of social and emotional reciprocity' (DSM-IV-TR) [5], '); ‘impaired or deviant response to other people’s emotions' (ICD -10) [16], 'difficulty expressing themselves, especially when talking about emotions' (definition of the National Autistic Society) [17], emotionally inappropriate behaviour… impairment of comprehension (Gillberg diagnostic criteria) [18] ... As it says Attwood [19], 'we now have a psychological term, alexithymia to describe other characteristics associated with AS, ie someone who has an impaired ability to identify and describe emotional states. Clinical experience and research have confirmed that alexithymia can be recognized in the skills and profile of people with AS. "

Conclusion: Based on the adults studied a significant comorbidity was confirmed between alexithymia and AS, leading to the question of whether alexithymia is an idiosyncratic feature of subjects with AS.


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Alexithymia Defined

The behaviour now known as alexithymia was first described in detail by psychiatrists Peter E. Sifneos and John C. Nemiah who were then working at the Beth Israel Hospital with patients displaying psychosomatic disturbances. Many of these patients showed extreme difficulties in talking about their emotions, and in 1972 Sifneos coined the word alexithymia meaning 'without words for emotions' (from the Greek a = lack, lexis = word, thymos = emotion) to denote the cluster of behaviours he was witnessing1….. Over the past few decades the alexithymia concept has been refined theoretically, where it is presently defined by the following features: (i) difficulty identifying feelings and distinguishing between feelings and the bodily sensations of emotional arousal; (ii) difficulty describing feelings to other people; (iii) constricted imaginal processes, as evidenced by a paucity of fantasies; and (iv) a stimulus-bound, externally oriented cognitive style.4

Difficulty identifying and describing feelings

Individuals with alexithymia have difficulty recognizing emotional states as they are happening. They may on later reflection gain a vague sense that they were in the grip of a strong emotion like tearful sadness or rageful anger but are usually at a loss when trying to piece together what caused such emotions to manifest, i.e. they cannot picture what stimulated the mood. At most they might have an uncomfortable sense of something changing inside their body- increased heart rate, blushing, or butterflies in the stomach, and when pressed to give an account of their feelings an alexithymic will have no words to offer, may fumble with a contrived answer or simply change the subject.

More often the individual will misread the physical expression of emotion as a physical expression of diseases, i.e. where the tears on the cheek become not sadness but a defective tear duct; the racing heart of passion, a faulty valve; or an anxious tightening in the stomach, appendicitis. Alternatively, emotional states may be blamed on adverse environmental influences such as a change in the barometer, poisons in the air, or an uncomfortable mattress. It is as if there were a missing link allowing imagination to form a picture of the emotional situation for the mind to work with. This then leads to the next point regarding the importance of imagination (and it's lack) in articulating clear thought, for as Aristotle said- "The mind never thinks without a picture".

Constricted imaginal processes

Imagination is a complex phenomenon requiring definition before detailing its absence in alexithymic states. It is often understood as the ability to form pictures in the mind -zerox-like- from the remembered stuff of our concrete sensory experiences. A closer evaluation of imagination shows it to be more complex, capable of creating novel images never before seen in the concrete world, yet still drawing on the bric-a-brac of scattered sensate memories to form its collages. Imagination can also present in ways other than quasi-pictorial images, where for instance one can imagine a smell, a sound or conversation, or a physical sensation on imaginary fingertips.

'Imagining' as we have described it here serves several important functions, such as our ability to imagine what our emotions, wishes, desires or needs are and how we would like to fulfil them; how we might imagine past and present day conflicts; how we might regulate the type and intensity of our emotional expression; and how to imagine ourselves in another person's shoes, which latter lays the basis for empathy and the ability to be effective in modulating the emotional states of others.

American philosopher Edward S. Casey has also added a further layer to our understanding of imagination, namely the "controlledness" or "spontaneity" of any given act of imagining.5 Controlled imagining is characterized by a wilful effort to manipulate images in the mind, such as when we deliberately 'use our imagination,' whereas spontaneous imagining is strictly uncontrolled, unpredictable, involuntary, and surprising. Casey shows how these two potential traits of imagining are exclusive, meaning that when we imagine it will be either spontaneous or controlled in character in a given moment and cannot be both "at the same time," although in practice the two acts of imagining often appear in close proximity and can give rise to each other in a symbiotic interplay...

Whilst most literature on alexithymia does not discriminate which trait of imagining is in deficit, and which isn't, many alexithymic individuals do display a capacity for sophisticated controlled imagining, consciously using imagination for practical means such as how to work out a problem or construct a useful idea or object, an ability suggesting that spontaneous imagining is the specific deficit in question. Several writers have noted this absence of spontaneity in alexithymic imagining, notably Joyce McDougall, Fain and David, and John H. Krystal. It is this second sense of imagining as spontaneous which carries the necessary experiential images of what we are physically emoting, providing for further utilization to recognize, think about, and verbalize one's feelings.6

These terms are therefore useful for discriminating which trait of imagining is, and is not, available to the alexithymic mind. Intellectually controlled imagination is available, but the spontaneous emotional imagination is in deficit. One explanation for this preference may be that in controlled imagining images can be selected which are void of affective or instinctual-drive representations (and are therefore non-threatening), whereas products of imagination incited in conjunction with spontaneous emotional experience carries unacceptable threats of engulfment to the individual’s fragile sense of self. (see heading on 'psychogenic alexithymia')

Stimulus-bound, externally oriented cognitive style

Without an ability to orient themselves within a recognizable world of feelings, alexithymics are forced to orient their existence toward the more limited areas of competence remaining to them; functioning impersonally in the concrete physical world of external things. Indeed they are superadapted to the 'thing world' of sensate realities, material objects, and empirical facts to which they apply their often impressive intellectual prowess with equal fixity. For this reason they are sometimes described as "human robots" akin to the Tin Man from the Wizard of Oz who must chop his wood and think his thoughts without input from a human heart.

The meaning of being 'stimulus-bound' and 'externally oriented' comes very close to Carl Jung's early conception (1921) of the 'extraverted sensing type' which has been more recently elaborated by the Myers-Briggs typologies. As Jung puts it:

No other human type can equal the extraverted sensation type in realism. His sense for objective facts is extraordinarily developed. His life is an accumulation of actual experiences of concrete objects, and the more pronounced his type, the less use does he make of his experience. In certain cases the events in his life hardly deserve the name "experience" at all. What he experiences serves at most as a guide to fresh sensations; anything new that comes within his range of interest is acquired by way of sensation and has to serve its ends.7

Jung's reference to experience refers to the psychical elaborations of sensate activities, the ability to reflect on sensate happenings in a subjective imaginative way. He asks, 'What would the thing be worth if the psyche withheld from it the determining force of the sense-impression? What indeed is reality if it is not a reality in ourselves, an esse in anima? Living reality is the product neither of the actual, objective behaviour of things nor of the formulated idea exclusively, but rather a combination of both in the living psychical process, through esse in anima.... The only expression I can use for this activity is fantasy."8

A few decades after Jung, studies of the externally oriented cognitive style were brought into focus with the French publication of pensee operatoire by Marty M'Uzan,9 who described utilitarian thinking and absence of fantasy in physically ill patients. The significance of these early observations were investigated by Nemiah and Sifneos10 who studied the cognitive style of psychosomatic patients. Their studies confirmed that many patients with psychosomatic diseases have a communication style characterized by a preoccupation with the minute details of external events and by an absence of fantasies. Around this time Henry Krystal was also observing these characteristics in posttraumatic stress disorder patients,11 whilst similar characteristics were being found in drug addicted individuals, personality and eating disorders, and these findings have been replicated by numerous researchers to date.

Accompanying this style of functioning may be a propensity to be guided by strict rules, regulations, and social conformity which provide existential anchoring via their predictable codes of behaviour, rather than by feelings which for the alexithymic individual provide no such security. Children of, and those in close relationships with alexithymic individuals sometimes report the presence of moralism and pedantry, and may at times feel imprisoned by monotonous recountings of chronological facts or mundane details of the daily round; all externalities which sure-up the predictabilities of the alexithymic world orientation. [Excerpted from 'Blocked Imagination~ Emptied Speech’ – by Jason Thompson]


1. P. E. Sifneos - The prevalence of 'alexithymic' characteristics in psychosomatic patients. Psychotherapy and Psychosomatics 22, 255-62 (1973). Sifneos systematically investigated the cognitive style of patients suffering from classical psychosomatic diseases.

4. Nemiah, Freyberger & Sifneos, 1976; Taylor, 1994; Taylor, Bagby & Parker, 1991. Cited in Disorders of Affect Regulation: Alexithymia in Medical and Psychiatric Illness (1997)

5. Edward S. Casey's- Imagining: A Phenomenological Study (Studies in Continental Thought) See particularly his chapter 'Spontaneity and Controlledness' which lays the groundwork for a more detailed study of imagination as it appears in the context of alexithymia.

6. Antonio Damasio- The Feeling of What Happens: body and emotion in the making of consciousness (1999). Damasio writes "Even the feelings that make up the backdrop of each mental instant are images, in the sense articulated above, somatosensory images, that is, which mostly signal aspects of the body state." (p. 319) The author posits the relevant chain of events (or lack thereof) as Emotion - Mental Image - Knowing.

7. Carl Gustav Jung- Psychological Types Vol. 6 CW. extroverted sensing type p. 352 (ninth printing- 1990)

8. Ibid. p. 51-52

9. Marty M'Uzan- La 'pensee operatoire'. Revue Francaise de Psychoanalyse, 27, 1163-77 (1963)

10. P. E. Sifneos- Clinical observations on some patients suffering from a variety of psychosomatic diseases. Acta Medicina Psychsomatica, 7, 1-10 (1967). And C. J. Nemiah & P. E. Sifneos- Affect and fantasy in patients with psychosomatic disorders. In O. W. Hill (Ed), Modern trends in psychosomatic medicine. (1970).

11. Henry Krystal- Massive Psychic Trauma. New York: International Uni Press (1968).


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