Sunday, March 4, 2007

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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