Alexithymia: Signs, Diagnosis, and Healing

Alexithymia: Do You Have Words For Your Feelings?

Alexithymia is something you can heal from. Trapped under an alexithymic exterior is an excruciatingly sensitive and empathic soul. If you give yourself a chance, and courageously embark on the path to reclaim your emotional sensitivity and intensity, the reservoir of aliveness is within grasp.

Being able to feel and express emotions are your birthrights. From the moment you come into this world, you feel a myriad of emotions in response to life circumstances. Some of these feelings are pleasant, some unpleasant, some confusing, and some frightening. If you have emotionally available and attuned caregivers, you will learn to regulate yourself, and grow to be an adult who can tolerate a wide range of emotions. In an ideal scenario, even emotions that are often deemed ‘negative’ or taboo by our culture and society, such as anger, sadness, and regret, are given healthy channels to be expressed. Ultimately, it is only when you can be honest with yourself about your feelings that you can have a solid sense of self, and it is only when you have room to express authentically that a relationship can be sustainably fulfilling.

What happens, then, if the channel via which you feel, and express emotions is blocked? You may end up feeling empty, confused, disconnected, and alone. This is the world someone with ‘Alexithymia’ dwells in. Don’t be too surprised if you have not heard of this term, as even many mental health professionals are not aware of this condition and do not understand the invisible pain it generates.

It may seem paradoxical that someone who is innately emotionally sensitive and intense can also be emotionally ‘blocked’, but the situation is more common than you think. An understanding of the trauma pathway will help us make sense of alexithymia’s relationship to emotional intensity. 

“Anyone who has a continuous smile on his face conceals a toughness that is almost frightening.”
― Greta Garbo

 

What is Alexithymia?

Alexithymia literally means ‘no emotions for words’ in Greek. When you have Alexithymia, you have difficulty identifying and describing feelings and must rely on what is known as ‘external oriented thinking’ (Nemiah and Sifneos 1970, Taylor et al., 1997), meaning you use external signals to make sense of the world rather than following your inner guidance. 

What might have happened was that due to an early trauma too painful to bear, you unconsciously cut off from your feelings. This ‘trauma’ may not be a typical ‘shock trauma’, but ‘cumulative developmental trauma’ (CDT), also known as early relational trauma (Isobel et al., 2017) or complex trauma. This type of trauma happens when you are trapped in a situation where your boundaries were violated repeatedly, cumulatively, over a period of time in which you had no route to escape (Sar, 2011). 

It may also not be what your caregivers did, but more so, what was missing. All children need to be attended to, shown that they matter and that they are being cared for. Prolonged childhood neglect, or having to deal with emotionally unstable, blank, or cold caregivers, could be as traumatic (if not more traumatic) than physical beatings.

As a result of your relational trauma, the feeling world has become something frightening; so you instead focus your mind on ‘external facts’ that on the surface seem more tangible, predictable, and reliable (Chung et al., 2016; Kupchik et al., 2007). This was a strategy you adopted to feel safer and gain some sense of control in a precarious world in which you were unprotected. Unfortunately, however, this is not a sustainable strategy. Unprocessed feelings will inevitably accumulate in your body, causing physical and neurological symptoms that seem disconnected from their sources (Pennebaker and Beall, 1986; Martino et al., 2019). You may have frequent headaches, fatigue, and panic attacks, without knowing why.

 

“My feelings are too loud for words and too shy for the world.”
― Dejan Stojanovic

 

Test for Alexithymia: What it is like to live in a world without Emotions

With Alexithymia, you may come across as socially awkward to others, as you do not automatically appear jolly on  ‘happy’ occasions. Your difference may cause you to be socially anxious and find gatherings unappealing. When unfortunate events occur, you may seem unusually stoic, and fail to receive the sympathy and empathy others offer you. This, however, does not mean you don’t feel things— physiologically, at least, you do. You may have physical symptoms or even suicidal ideations, but the sources of your distress remain a mystery to you.  To check if you have Alexithymia, see if you identify with the following:

 

Some Inner Signs of Alexithymia:

You are out of touch with your feelings. When you try to feel into your heart, you feel blocked.

Most of the time, you don’t get emotional nuances. You can only tell if you are feeling ‘good’ or ‘bad’, ‘happy’ or ‘unhappy’, and not much more beyond that.  

You cannot tell what others are thinking or feeling just by their body language and facial expressions.

In interactions, you don’t feel connected to other people – it’s as though there is a wall blocking you from them.

You feel alienated from your own body; you may have physical symptoms of panic attacks that seemingly come from nowhere.

You do not usually feel emotional but suddenly, you can become flooded with anxiety or burst out in rage.

While you crave intimacy, you find the prospect of close relationships daunting. They make you feel like you are losing control and put you too far outside of your comfort zone.

You may have lost your drive and motivation. You procrastinate at work and do not find much joy in any hobbies. Every day feels like a grind, simply getting through the day is difficult. 

You are not interested in things that have to do with imagination or fantasy and prefer the concrete and practical.

You are confused about your identity and lack a sense of self.

You feel empty and numb, as though you are just an observer of your own life. You know you are missing out on life but you don’t know how else you can live. 

 

Outward Signs of Alexithymia

You have blank facial expressions and do not smile or frown when it is ‘socially appropriate’ to do so.

You can find no words when you try to express emotions. If someone asks ‘how are you feeling?’ you reply with generic terms like ‘fine’ or ‘okay’. If someone specifically asks what you are feeling, you draw a blank.

You appear cold and unfeeling. Others may think of you as arrogant or aloof. 

Others may think you lack humor.

You use nervous laughter to fill in gaps, because silence makes you uncomfortable. 

As you struggle to express your needs and desires, others do not understand what you want and become frustrated.

When speaking you go into endless descriptive details without any personal feelings. Your speech may be monotonous, dry, and hard to follow. 

It’s important to note that having Alexithymia does not mean you are apathetic. You may still feel things deep inside, but you struggle to feel connected to your feelings or express them to others.

While not inherently dangerous, Alexithymia can lead to a myriad of interpersonal and relationship issues. In school and at work, you feel left out. In relationships and marriage, you are misunderstood as distant and disengaged. People you love are not able to feel your affection. You may also suffer from a lack of sex drive. Sadly, the inability to express affection also means you are more likely than others to end up with broken relationships. Being excluded and misread on all fronts can lead to a very lonely existence. 

On the surface, Alexithymia can seem like a ‘convenient’ strategy to deal with life. You may be able to temporarily ‘erase’ painful feelings, but by wiping away the lows, you also leave behind the highs. Without emotions, you will not be able to build positive memories with your loved ones, feel energetically charged with passion, or intimately connect to someone. You remain a clinical observer of your life, watching it go by without enjoying it. 

 

“Sometimes loneliness makes the loudest noise.”
― Aaron Ben-Ze’ev

 

Alexithymia as a Diagnosis

Alexithymia is not recognized as a mental disorder on its own. It was first introduced into the lexicon of psychiatry in the year 1976 by Peter E. Sifneos, a psychiatrist and professor emeritus of psychiatry at Harvard Medical School. Today, there still remains a lack of information on the underlying causes and recommended therapies.

What makes matters more difficult is the inability of the alexithymic to ‘tell their stories.’ You may act out (through anger, self-harm, and even suicide attempts) without being able to offer any explanation for your actions. In the absence of a first-hand account of what happened, diagnosis becomes difficult.

Certain social demographic factors are more likely to put a person at risk of Alexithymia. While it’s estimated that 13 percent of the population suffers from Alexithymia, the prevalence among men is almost twice that of women. 

Alexithymia can occur at two levels – as a primary trait or as a secondary state. Primary Alexithymia implies that the individual is born with a genetic defect that hampers the ability to feel and express emotions and empathize. It’s also linked to brain damage, particularly to the anterior insula (responsible for visceral sensory and motor responses and somatic sensory reactions, especially in the face, tongue, and upper limbs). This neurological defect can be a congenital condition or the result of an injury that occurs later in life.

Much of the research available, however, is focused on secondary Alexithymia, which is usually a response to traumatic life events as either a child or adult. 

Alexithymia can be perpetuated by the presence of a host of other conditions, such as;

· Obsessive-compulsive disorder

· Binge eating disorder

· Schizophrenia

· Substance abuse

· Childhood neglect and emotional abuse

· Life-altering illnesses

· Autism

· Depression

Alexithymia and Autism

A stereotypical understanding of the autism spectrum disorder (ASD) is that it entails a lack of empathy, a theory which has been largely debunked. An alexithymic person’s failure to recognize intense feelings (such as confusion or danger) in others, and their lack of emotional expression means that Alexithymia is often misinterpreted as autism.

While individuals on the autism spectrum can also exhibit traits of Alexithymia, research on the correlation between the two conditions is inconclusive. The existing consensus seems to be that Alexithymia often occurs with autism and is not caused by autism. (Here is more on High Functioning Autism)

Alexithymia and Depression

People who suffer from major depressive disorders and postpartum disorders are more likely to suffer from Alexithymia. A person with Alexithymia is twice as likely to also experience depression. But at the same time, research shows that symptoms of alexithymia decline with a reduction of symptoms of depression. Therefore, it is not possible to say whether Alexithymia is a cause or consequence of depression.

Alexithymia and Trauma

People who experience PTSD are more likely to develop Alexithymia. A study of Vietnam veterans with post-traumatic stress disorder revealed that 41 percent of them were alexithymic. A similar survey of holocaust survivors revealed that those with PTSD scored  significantly higher when tested for Alexithymia than those without PTSD.

Alexithymia and Neurological Disease

Patients with neurological diseases and conditions such as traumatic brain injury, stroke, dystonia, Huntington’s disease, multiple sclerosis, Parkinson’s disease, and epilepsy are more likely to have Alexithymia.

Alexithymia and Early Childhood Emotional Abuse and Neglect

Alexithymia is most likely caused by a combination of both biology and environment. In other words, some might be born more prone to alexithymia than others, and then experience traumatic events or relational wounds that serve as the final triggers. 

From a developmental perspective, alexithymia is a result of the disruption in one’s emotional development as a child. It may be that your parents were depressed, cold, and distant, and were not able to mirror your feelings back to you or attune to you. Or, they might be afraid of emotions themselves and therefore punish you for expressing them. They may lack a language of feelings, and thus have  never modeled for you what it means to be emotionally literate. 

If as a sensitive and intense child you were repeatedly belittled, blamed, or scapegoated for your natural expressions, Alexithymia would be a natural outcome. Perhaps you had never felt safe to express yourself. The message you received was that if you ever expressed anything that was ‘inconvenient’ to the adults, such as disappointment or anger, you risked being rejected, abandoned, or punished. In some households, even joy and excitement were discouraged. With your intensity, your natural exuberance might be deemed as ‘too much’ and therefore be shut down. 

For some time it was thought that emotional neglect was the only child maltreatment uniquely associated with Alexithymia. However, other research has shown that a history of abuse is also linked to Alexithymia (Berenbaum, 1996; Joukamaa, et al., 2008). This makes sense— imagine being punished every time you express emotion. Eventually, you will learn to stop crying or speaking up just to stay safe. 

Several questionnaires are used to help patients and therapists identify Alexithymia. The most popular among them is the Toronto Alexithymia Scale 20 (TAS-20, Bagby, Parker & Taylor, 1994) that assesses Alexithymia in adults. There is also a version that can be administered to children. Depending on the initial assessment, an MRI may be suggested to assess any damage to the insula in the brain.

Therapy and Coaching for Alexithymia

Historically, it has been known that engaging individuals with alexithymia poses a challenge for therapists, primarily due to their tendency to avoid emotional exploration. The emotional barrier created by those with alexithymia makes it difficult for therapists and coaches to establish a connection or to explore the deeper layer or their childhood trauma or emotional wounds. However, the key aspect often overlooked is the highly sensitive soul that is concealed beneath the emotionally guarded exterior. It takes particular insights and skills for a professional to see beyond their defenses into the softer layer underneath.

Peeling away those emotional layers isn’t just about breaking down resistance; it is about revealing the deep emotional complexities that have been tucked away for a long time. For therapists and coaches dealing with alexithymia, it means being extra tuned in to the subtle cues and having a toolbox of skills that go beyond the usual approaches.

Building trust, showing empathy, and creating a safe space are crucial. It’s a gradual process of helping these individuals let down their guard and express emotions that might have been bottled up for years.

Traditional therapeutic modalities, such as cognitive-behavioral therapy (CBT) and psychoanalysis, are commonly employed. CBT focuses on identifying and modifying thought patterns, while psychoanalysis delves into unconscious processes. While these approaches offer valuable insights, they may not comprehensively address the emotional complexities of alexithymia. In my experience (Imi) , approaches such as relational-based psychodynamic therapy, RO-DBT and Internal Family System have a special space when it comes to treating Alexithymia.

Relational psychodynamic therapy

Relational psychodynamic therapy is a therapeutic approach that emphasizes the significance of interpersonal relationships in shaping someone’s emotional well-being and psychological development. Rooted in psychodynamic principles, this therapeutic modality explores how early relationships and experiences impact current patterns of relating to oneself and others.

The core premise of relational psychodynamic therapy is that our past relationships, especially those formed during childhood, influence our present thoughts, emotions, and behaviors. The approach seeks to uncover and understand the dynamics of these past relationships, believing that doing so can illuminate recurring patterns and contribute to personal growth.

Relational psychodynamic therapy recognizes that the therapeutic relationship serves as a microcosm for the client’s broader relational patterns. By examining how the client relates to the therapist, insights emerge into their relational style outside of therapy, providing valuable information for personal growth and change. The goal is not only symptom relief but also the development of a more authentic and fulfilling way of relating to oneself and others.

Radically Open Dialectical Behavior Therapy (RO-DBT)

Radically Open Dialectical Behavior Therapy (RO-DBT) is a specialized form of therapy designed to address certain personality traits and behaviors associated with over-control. While it wasn’t initially developed specifically for alexithymia, some aspects of RO-DBT make it a potentially beneficial approach for individuals with this condition.

RO-DBT places a particular emphasis on addressing excessive self-control and emotional over-control. This is in contrast to traditional Dialectical Behavior Therapy (DBT), which typically focuses on emotional dysregulation and impulsivity. Alexithymia, characterized by difficulty identifying and expressing emotions, often involves a heightened level of emotional control and an avoidance of emotional experiences.

RO-DBT addresses the importance of social signaling, which involves non-verbal cues and expressions that communicate emotions in social interactions. Enhancing social signaling skills can be relevant for individuals with alexithymia, as they may struggle with recognizing and responding to emotional cues in others.

RO-DBT encourages mindfulness and openness, which can contribute to a more receptive attitude toward one’s own emotions. For those with alexithymia, cultivating mindfulness may help in becoming more aware of emotional experiences without feeling too threatened.

RO-DBT emphasizes the importance of flexibility and adaptability in social interactions. This can be beneficial for individuals with alexithymia who may have rigid patterns of relating to others. The therapy encourages a more open and flexible approach to social situations.

Internal Family Systems (IFS)

Internal Family Systems (IFS) is a therapeutic approach that views the mind as a system of various subpersonalities or “parts.” Developed by Richard Schwartz, IFS posits that within each person, there are different facets or parts, each with its own feelings, thoughts, and roles. These parts may operate in harmony or create internal conflicts, influencing an individual’s emotions and behaviors.

IFS provides a structured framework for exploring and understanding the different parts within an individual. This is particularly relevant for those with alexithymia, as it allows them to dissect and differentiate their emotional experiences, potentially leading to a better grasp of their feelings.

IFS emphasizes the concept of Self, which is considered the core, undamaged, and compassionate aspect within an individual. By fostering a connection with the Self, individuals with alexithymia can develop a more compassionate and understanding relationship with their emotions.

IFS seeks to facilitate harmony and cooperation among different internal parts. This can be beneficial for individuals with alexithymia who may experience internal conflicts or struggle with integrating their emotional experiences. By fostering internal cohesion, IFS supports a more balanced and integrated sense of self.

IFS adopts a non-pathologizing and non-pathogenic stance toward emotional experiences. This approach can be especially valuable for individuals with alexithymia, as it creates a safe and non-judgmental space for exploring emotions without overwhelming or pressuring them.

Integrating mindfulness practices and techniques to enhance emotional awareness can complement therapeutic or coaching interventions. Mindfulness encourages people to observe their thoughts and emotions without judgment, fostering a more conscious and attuned relationship with their internal experiences without feeling overly threatened.

Stoicism Coaching and Alexithymia

Stoicism, an ancient philosophical school of thought originating in Greece, offers a unique perspective on emotions and personal development. While Stoicism is often associated with principles of emotional detachment, its application in coaching individuals with alexithymia requires a nuanced approach.

Central to Stoic philosophy is the idea that individuals have control over their responses to external events, even if they cannot control the events themselves. The Stoics encourage cultivating an inner resilience that allows one to navigate life with a calm and rational mind.

For someone with alexithymia, , the Stoic emphasis on rationality and self-mastery may resonate. Stoicism teaches us to view emotions as judgments and reactions within their control, empowering us to approach emotions with a measured and intentional mindset.

Stoicism coaching can provide valuable tools for those with alexithymia to navigate their emotional terrain. By incorporating Stoic principles into coaching sessions, individuals can learn to observe their emotional responses without being overwhelmed by them. This approach aligns with the Stoic idea of maintaining an inner sanctuary of tranquility despite external circumstances.

Quoting Epictetus, who said, “We cannot choose our external circumstances, but we can always choose how we respond to them,” Stoicism coaching can help individuals with alexithymia recognize their agency in responding to emotions. The coaching process may involve practical exercises in observing emotions without judgment, fostering self-awareness, and cultivating a mindset that promotes resilience in the face of emotional challenges.

While Stoicism can be a valuable framework for individuals with alexithymia, coaches must exercise caution in reinforcing emotional detachment. The Stoic emphasis on not being ruled by emotions should not be misconstrued as suppressing or negating emotions altogether. Seneca’s wisdom, “It’s not that we have a short time to live, but that we waste much of it,” serves as a reminder that life is finite, and emotions, even challenging ones, are part of the human experience.

Coaches working with individuals with alexithymia must strike a balance between Stoic principles and acknowledging the importance of emotional expression. Suppressing emotions entirely can hinder personal growth and authentic connection with oneself and others. Instead, the coach should encourage the individual to explore and understand emotions, using Stoic principles as a guide for responding thoughtfully.

By integrating Stoic wisdom with an understanding of the unique challenges faced by individuals with alexithymia, coaches can create a coaching experience that fosters self-awareness, resilience, and a balanced approach to emotions.

To conclude, in the pursuit of effective treatment for alexithymia, a nuanced understanding of the condition is paramount. While traditional approaches like CBT and psychoanalysis play valuable roles, relational psychodynamic therapy and Internal Family System may be some avenues for addressing the emotional complexities inherent in alexithymia. Ultimately, a personalized and holistic approach that considers the individual’s unique emotional landscape is key to successful outcomes.

 

Coming out of Alexithymia

The treatment approach for Alexithymia itself may have to be different from typical therapy approaches because we are working with someone who cannot even identify or name their feelings. For instance, research shows that psychoanalysis during which the therapist’ ‘blank-screens’ could be too confrontational or threatening and is not a good match (Lesser, 1981; Sifneos, 1975; Taylor, 1984). However, since Alexithymia often occurs along with other mental disorders, the treatment of those conditions can help reduce the Alexithymia.

As discussed, having Alexithymia does not mean that you do not feel, or that you are cold and need no human connection. It does not mean you are a bad person or that you never empathize with others. All it represents is a blockage in your feeling channel, coupled with a form of ‘emotional illiteracy’. Therefore, one of the biggest milestones in your journey to healing is finding a language for your feelings. This is known as ‘building emotional literacy’. A tool that can be useful in this process is the ‘emotional wheel’. Developed by psychologist Robert Plutchik, this handy tool allows you to learn about emotions in varying degrees of complexity and nuance.  With training, you can slowly build up a set of vocabularies and link them to your inner states. There are plenty of online resources on the emotional wheel, such as this one. 

There are other tools you can use to find a connection with your inner world. For example, researchers have found that expressive writing can help you build internal awareness and bridge your feelings with words, especially if you practice it every day.  Reading novels that involve personal narratives will help get you out of the rut of monotonous narration. Expressive arts therapies such as art-making, dance, and music can be good ways to express yourself non-verbally. 

In my experience, when it comes to Alexithymia, the biggest healing happens within relationships. Since the original wound likely happened in a relational context, it must also be healed in a relational way. It may be a relationship with an enlightened friend or a therapist/coach. Ideally, your therapist or coach will create an environment where you — both the adult you and your inner child— genuinely feel safe enough to feel and express emotions. Where words are lost, they can gently guide you by providing vocabulary or by modelling authentic expressions of their own emotions. A degree of self-disclosure on their side, showing that they, too, feel things, can help you feel safer and empowered to do the same. Wherever appropriate, they will encourage you to name your feelings, though this does not entail forcing you to do things you cannot do. 

One important juncture in the process is when you feel or have to express feelings that are hard for your therapist/coach to receive. If you have been shut down in the past, feelings such as anger or disappointment in another person can be very difficult for you. It is critical that the therapist/coach does not, due to their own fears or vulnerability, punish you for expressing these ‘negative’ feelings towards them. If they do, they are simply repeating what your early caregivers had done to you. Therefore, it is important that you ideally engage someone who has worked on themselves, is genuinely mature in an emotional sense, and is not hiding behind a ‘professional facade’. It can be life-changing for you to experience, maybe for the first time in your life, a genuine, trusting, and lasting relationship in which all expressions are allowed. The experience you have with a professional can then be generalized and brought to other aspects of your life, such as your friendships or an intimate relationship. 

Alexithymia is not something that cannot be changed. This may be counter-intuitive, but more likely than not what is trapped under an alexithymic exterior is an excruciatingly sensitive and empathic soul. Shutting down emotionally was never your conscious choice; it was what you were pushed to do to survive painful situations.

If you give yourself a chance, and courageously embark on the path to reclaim your emotional sensitivity and intensity, the reservoir of aliveness is within your grasp.

 

“What happens when people open their hearts?”
“They get better.”
― Haruki Murakami, Norwegian Wood