Constructs often confused with Alexithymia

What Alexithymia Isn't

Alexithymia is sometimes loosely characterised as a lack of emotional expression or reactivity. Unfortunately this leads to a confusion with other psychological concepts which are distinct in a number of important ways.

The original concept of alexithymia - defined by Sifneos and used implicitly by most authors - is clearly distinct from each of the following conditions.

Sociopathy

Sociopaths and psychopaths are emotionally unresponsive. So are alexithymics. This apparent similarity has inspired some people to suggest that sociopathy is caused by alexithymia. That's a serious misconception. Alexithymics are habitual social conformists, not social menaces. The difference in disposition and attitude between sociopaths and alexithymics is usually obvious to a trained clinician.

Sociopaths and alexithymics are emotionally unresponsive in very different ways. Sociopaths are known to be emotionally underaroused. They engage in vigorous or dangerous activities to try to attain normal levels of arousal. This is quite the opposite of alexithymia. Unlike sociopaths, alexithymics experience high levels of emotional arousal, but believe it to have a physical cause. They are particularly vulnerable to stress and thus are unlikely to engage in dangerous or criminal activities. Conversely, sociopaths are unlikely to be alexithymic. The reduced physiological reactivity of sociopaths precludes the psychosomatic trauma implicit in the original version of the concept.

Despite this conceptual difference, it is possible that future studies may show a positive correlation between sociopathy and alexithymia, especially if the Toronto definition is used as the sole measure of alexithymia (which the authors caution against). It is arguable that sociopaths show many of the superficial properties that are key to the TAS-20. They rarely talk about or pay attention to their emotions, and they do not respond emotionally to thoughts and situations that would normally be considered highly emotive. Although they are often goal-oriented, they have a paucity of dreams and fantasies and seem continually bound to the here-and-now. These characteristics all count towards the TAS-20 score. So the TAS-20 risks identifying sociopaths as alexithymic, though the hypothesised psychological abnormality is very different. This means that if the TAS-20 is used to select alexithymic subjects for research, and there is an unusually high level of sociopathy amongst the experimental group, the results may show a slight positive but misleading correlation between alexithymia and sociopathy.

Stoicism

The ancient Stoic philosophers urged people to resist their emotional impulses. In the modern sense of the term, stoics are people who accept adversity without complaint, refusing to get excited or emotional when the unexpected happens.

Habitual or ideological stoics might well appear alexithymic. They are unlikely to explain their actions in terms of emotions and they attach very little import to their dreams or fantasies. Yet there is no implied cognitive, affective or emotional impairment. They do not fail to interpret their own emotions or feelings. They just refuse to obey them, and with practice can learn to avoid eliciting them in the first place (see the section on apathy).

But genuine stoics are not alexithymic and alexithymics are only superficially stoic. Stoicism is all about recognising one's emotions and reducing their effects by cognitive deliberation. This is quite the opposite of the disorder believed to lie at the heart of alexithymia. Alexithymics, so the theory goes, are unable to identify or regulate their emotions properly. Stoics depend on it.

Apathy

Apathy is the absence of emotion, particularly in situations normally considered highly emotive. Apathy also implies the absence of physiological activity in response to emotive thoughts.

Superificial definitions of alexithymia may not sufficiently distinguish it from apathy. Most alexithymics appear apathetic. Yet apathy and alexithymia are clearly distinct. Almost every expert agrees that alexithymics do exhibit physiological activity characteristic of emotion - it is just that this activity isn't correctly interpreted as emotional. So apathy excludes affective physiological activity and alexithymia requires it.

Emotional repression

In the psychoanalytic paradigm, repression is a psychological defence mechanism by which challenging emotions are rendered unconscious. However, they continue to disturb the psyche and find expression in a variety of surreptitous ways. People with repressed emotions may therefore deny having certain emotions, despite showing the telltale physiological symptoms. They cannot deal appropriately with emotions they refuse to acknowledge, and psychosomatic illness may result.

Repression responds very well to conventional psychotherapeutic treatments - alexithymia does not. In repression, the patient subconsciously understands the nature of his or her feelings and (sometimes) the cause of those feelings, and this subconscious comprehension generates neurotic conflict. He or she gives out subtle clues about their hidden feelings, by means of sublimated fixations or dream content. The job of the psychoanalyst is to encourage the patient to consciously acknowledge the subconscious train of thought, bringing it to the fore so that it can be properly addressed.

This is not the case with alexithymia. The alexithymic person is genuinely unable to comprehend the meaning of his or her feelings, even on a subconscious level. There is no surreptitious expression of genuine emotional attitudes, no neurotic conflict or complex psychological symbolization. Alexithymics have no emotional story to tell. There is just pain, nausea, and discomfort.

Sifneos originally intended the alexithymia concept to be distinct from subconscious emotional repression. He still maintains that alexithymia is a symptom of an organic disorder. By contrast, emotional repression is a sign of psychological conflict, in which patients process their emotions correctly but have personal reasons for failing to acknowledge the results. However, it is not clear that the operational definition of the TAS-20 is sensitive to this distinction. As a result several theorists now contend that emotional repression is a major cause of alexithymia.

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