Medical Alexithymia / An Extensive Paper

My question for ASD / Asperger people: does this paper (Assessment of Alexithymia in medical settings) actually describe our “subjective” experience of interoperception?

What is that?

SEE: Interoception and emotion http://www.sciencedirect.com/science/article/pii/S2352250X17300106

Influential theories suggest emotional feeling states arise from physiological changes from within the body. Interoception describes the afferent signaling (in the direction of the central nervous system), central processing, and neural and mental representation of internal bodily signals… more

How is this physical phenomenon “different” in Asperger people? Don’t expect to find the answer here! 

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 J Pers Assess. (Click for full paper) Author manuscript.
Some nips and tucks for length…it’s a long paper. And yes, I loose my tolerance for nuttiness hallway through…

The Assessment of Alexithymia in Medical Settings: Implications for Understanding and Treating Health Problems

History and Definition of the Alexithymia Construct

The term alexithymia literally means “lacking words for feelings” and was coined to describe certain clinical characteristics observed among patients with psychosomatic disorders who had difficulty engaging in insight-oriented psychotherapy (Sifneos, 1967). Alexithymic patients demonstrate deficiencies in emotional awareness and communication and show little insight into their feelings, symptoms, and motivation. When asked about their feelings in emotional situations, they may experience confusion (e.g., “I don’t know”), give vague or simple answers (“I feel bad”), report bodily states (e.g., “my stomach hurts”), or talk about behavior (“I want to punch the wall.”). Such patients in psychodynamic psychotherapy have been described as unproductive, unimaginative, boring, and stiff. Therapists often have difficulty establishing working alliances with them, and such psychotherapy appears to lead to little benefit.

The alexithymia construct was originally conceptualized by Nemiah, Freyberger, and Sifneos (1976) as encompassing a cluster of cognitive traits including difficulty identifying feelings, difficulty describing feelings to others, externally oriented thinking (concrete), and a limited imaginal capacity. This original view of alexithymia has been the most influential in contemporary theory and research (Taylor, Bagby, & Parker, 1997). An alternative conceptualization, that alexithymia is a global impairment in emotional processing resulting in limited emotional expression and recognition (Lane, Sechrest, Riedel, Shapiro, & Kaszniak, 2000), has been less influential thus far. Yet, both definitions agree that alexithymia is a deficit, inability, or deficiency in emotional processing rather than a defensive process, and this deficit view is gaining increasing support from basic laboratory research. (more)

Other psychological constructs seem similar to alexithymia and may be confused with it. Although a full presentation of these other constructs is beyond the scope of this paper, we briefly describe several and contrast them with alexithymia. Some constructs represent emotional skills, abilities, or strengths, rather than deficits or limitations. For example, emotion regulation is broader than alexithymia and refers to a wide range of processes, including being aware of emotions, accessing and expressing emotions, and monitoring and controlling emotions (Dahl, 2003). Emotion regulation is so broad that it is difficult to define, and there are no assessment devices that capture the full range of emotion regulation processes. Emotional intelligence also is broader than alexithymia, and the leading theorists propose four characteristics: perceiving emotions in others, using emotions to facilitate thought, understanding emotions, and managing emotions (Mayer, Salovey, Caruso, & Sitarenios, 2001). Whereas alexithymia refers to basic emotion processes, emotional intelligence refers more to the application or implications of such basic emotional abilities. Other constructs are narrower in scope than alexithymia, including emotional awareness (Lane & Schwartz, 1987), emotional approach coping (Stanton, Danoff-Burg, Cameron, & Ellis, 1994), and meta-mood skills (Salovey, Mayer, Goldman, Turvey, & Palfai, 1995). These constructs typically exclude the cognitive aspects of alexithymia, (limited imaginal ability and externally oriented thinking), are newer on the psychological landscape than alexithymia, and have generated little literature relevant to their assessment in medical or mental health settings. (These two “aspects” are now part of alexithymia, the psychology version, with obvious negative prejudice as to what constitutes “imagination” – imagination=neurotypical magical thinking – and  the judgement that “concrete thinking” is pathological.) 

Several other emotion-related constructs are sometimes confused with alexithymia. Emotion suppression, inhibition, isolation, denial, and repression—like alexithymia—imply limited emotional insight and expression. Yet these constructs refer to active, defensive processes that reduce the experience or expression of emotion, whereas alexithymia is considered to be a deficit or deficiency rather than a defense. Defenses have long been the focus of psychodynamic and experiential psychotherapies, which attempt to lower or bypass them in order to facilitate emotional awareness and expression. Finally, low psychological mindedness overlaps with alexithymia (Shill & Lumley, 2002), but psychological mindedness places less emphasis on emotion than does alexithymia. The current review article will focus only on alexithymia, for which a very large literature has been generated, particularly in medical and psychiatric contexts.

The Assessment of Alexithymia

The most common approach to assessing alexithymia in applied settings is clinical judgment, and the two cases presented above were judged to be alexithymic during the course of psychotherapy. Yet, this time-worn clinical practice is of dubious psychometric quality, given that the interactions with the patient and the observations are not standardized, there are no criteria to define alexithymia and distinguish it from other constructs, and interrater reliability is unknown. Advancements in both research and clinical practice call for a more psychometrically sound approach.

Note: History of assessment tools follows – (bypassed here for the sanity of reader) 

We present measures according to the type of assessment method used—interview-based, collateral informant, projective testing, verbal responses, and self-report—and provide information on their psychometric status and utility. At the end of the article, we revisit alexithymia measurement as we explore several controversial and emerging issues…

…By far, self-report is the most widely-used approach to assessing alexithymia.

Although there is ongoing debate about the comparative validity of various alexithymia assessment approaches, the vast majority of studies have used only the TAS or TAS-20. Thus, as we evaluate alexithymia assessment in medical and mental health settings, a debate over specific measures is largely moot. Instead, we turn to our primary goal of this article, which is to answer these applied questions: What does knowing that a patient is relatively alexithymic tell the medical or mental health practitioner about the patient? Of what utility is the assessment of alexithymia in health care settings

The Utility and Validity of Assessing Alexithymia in Medical settings

Alexithymia was first described in people with classic psychosomatic disorders, and subsequent research has confirmed elevated levels of alexithymia in people with rheumatoid arthritis, essential hypertension, peptic ulcer, and inflammatory bowel disease (Taylor et al., 1997). Yet, studies have found elevated alexithymia in patients with a range of other conditions, including irritable bowel syndrome, cardiac disease, non-cardiac chest pain, breast cancer, diabetes, morbid obesity, chronic pain, eating disorders, substance dependence, pathological gambling, kidney failure, stroke, HIV infection, fibromyalgia, panic disorder, post-traumatic stress disorder (PTSD), erectile dysfunction, low sperm counts, chronic itching, and more. The growing recognition that alexithymia is not specific to psychosomatic disorders has led to the view of alexithymia as a risk factor for those medical, psychiatric, or behavioral problems that are influenced by disordered affect regulation (Taylor et al., 1997). Alexithymia is associated with a failure to use adaptive affect regulation processes such as modulating arousal, appropriately expressing or suppressing emotions, employing fantasy, obtaining and using social support, tolerating painful emotions, cognitive assimilation, and accommodation. (That is, screwed up emotional response and control, which probably applies to almost every human being , under specific conditions and at various and numerous times during one’s life?) By hindering these processes, alexithymia is hypothesized to be one of several factors that contribute to various physical and mental health problems, including undifferentiated negative moods such as depression and anxiety, compulsive or addictive behaviors, heightened or prolonged physiological arousal, physical symptoms, and potentially somatic disease (Taylor et al., 1997).

How did we get from “lacking words for feelings” to any and all human “problems”?

In an earlier article Lumley, Stettner, and Wehmer (1996) described several processes or mechanisms by which alexithymia may influence health and illness, including changes in physiological systems (e.g., autonomic, immune, endocrine), health behavior, cognitive processes (e.g., attributions, appraisals), and social relationships (e.g., social support, social models). The current paper complements and updates that earlier review.

In this article, we examine five domains of clinical interest that may be informed by the assessment of patients’ level of alexithymia: pathophysiology and somatic disease, symptom presentation, maladaptive behavior, response to treatment, and the possibility of reducing alexithymia. In the following sections, we critically examine the literature of each domain. Table 1 summarizes our interpretations of the literature for these five domains along with limitations of those interpretations. (see paper)

Does Alexithymia Contribute to the Etiology or Pathology of Somatic Disease?

A leading theory is that the alexithymic person’s (Hmmm… shift to alexithymic “aspects” become the person’s identity) failure to regulate negative emotions results in altered autonomic, endocrine, and immune activity, thereby producing conditions that are conducive to the development of somatic disease, although the specific disease that develops is determined by other factors (Taylor et al., 1997). What is the evidence for this theory? Studies of alexithymia and physiological processes are of two types—immune function and psychophysiologic activity (Guilbaud, Corcos, Hjalmarsson, Loas, & Jeammet, 2003).

Lab data here…

There are a number of limitations of these studies, however. The studies are limited to laboratories, and we do not know how alexithymia is related to psychophysiological activity in the natural environment. (Radically more important than lab results, since most humans don’t live in a lab) Also, it is possible that elevated resting sympathetic or cardiovascular arousal could result from adjustment to the novelty of the laboratory environment, or even to factors such as poorer aerobic conditioning or the use of arousing substances (caffeine or nicotine), which most studies do not assess or control. Also, the laboratory stressors that have been studied vary widely, and many are passive or contrived (e.g., viewing videos) rather than personally relevant stressors, which may yield different responses. Finally, different physiological measures yield different response patterns, particularly in response to different emotions, thus complicating interpretation of these studies further. (Mind-boggling “ditch-digging” that undermines the whole “shebang”)

Note: We still don’t have a clear medical definition of Alexithymia anywhere in this discussion so far. What the hell are we talking about? Another mysterious label that is so extended and diffused as to mean nothing!

In summary, although the literature has limitations and the findings are not entirely consistent, there is some evidence that people with alexithymia have more resting sympathetic and cardiovascular arousal as well as impaired immune status than people without alexithymia. (more)

Does Alexithymia Contribute to Symptom Reporting and Health Care Utilization?

Although there has been much interest in the possibility that alexithymia contributes to somatic disease, an alternative mechanism is that alexithymia influences illness behavior, particularly the experience and reporting of physical symptoms and seeking of treatment. The prolonged or heightened physiological arousal experienced by an alexithymic person might be experienced as aversive physical symptoms and reported as such. Relatedly, alexithymia may prompt a person to report only the undifferentiated physiological aspects of emotion but not the emotional label or the subjective, feeling aspects of emotion. Finally, alexithymia may prompt lead to somatosensory amplification, or the tendency to notice and be concerned about one’s body, which can be intensified by the low-level negative mood that often accompanies alexithymia. All of these processes are sometimes considered aspects of “somatization.” (The ubiquitous “It’s all in your head” diagnosis – and the classic presumption that children are just trying to get attention by pretending to be sick.)

Many studies have found positive associations between alexithymia and symptom reports. (data here)

Increased symptoms in alexithymic people would be expected to prompt health care utilization, and several studies support this proposal. (more)

The proposal that alexithymia drives the experience of symptoms and seeking of care rather than somatic disease may explain why some studies find similar levels of alexithymia among different patient groups, or between patients with “explained” versus “unexplained” symptoms … (more)

Does Alexithymia Contribute to Unhealthy Behavior?

Alexithymia also may contribute to poor health by prompting maladaptive or unhealthy behavior. Although behavior is influenced by many factors (e.g., environmental contingencies, modeling, attitudes), poor emotion regulation also may contribute to unhealthy behavior. For example, drug use and other compulsive actions may serve to modulate aversive arousal. Even behaviors such as safety, nutrition, or hygiene may be impeded by the failure to experience or recognize potentially adaptive feelings such as fear, guilt, or even self-pride.

Are the authors describing “neoteny”? That is, Alexithymia as the “inability to establish adult emotional stability” …another expansion of a “symptom” into a majority condition in Americans, as is now claimed for autism and mental illness? Hmmm…

There is consistent evidence that alexithymia is elevated in people with eating disorders, problematic gambling, and alcohol and drug abuse or dependence although perhaps not cigarette smoking and nicotine dependence. One comprehensive study found that, compared with controls, patients with eating disorders or alcohol- or drug-related disorders had similar, high levels of alexithymia, and a path analysis suggested that alexithymia predicted depression which predicted the addictive behavior in these disorders (Speranza et al., 2004). In addition, alexithymic people were found to have poorer nutrition and a sedentary lifestyle (Helmers & Mente, 1999) and a greater body mass index (Neumann et al., 2004). Alexithymia also is associated with a history of childhood maltreatment and subsequent self-injurious behavior (Paivio & McCulloch, 2004). Interestingly, alexithymia is related to less frequent sexual intercourse among women (Brody, 2003), thus possibly decreasing the risk of sexually transmitted diseases, although likely signaling interpersonal difficulties. Finally, an impressive, 5.5-year longitudinal study of 2297 middle-aged men found that alexithymia predicted increased risk of all-cause mortality, and the effect was even stronger for the risk of death due to injuries, suicide, or homicide, which suggests the importance of alexithymia-associated maladaptive behavior in these outcomes (Kauhanen, Kaplan, Cohen, Julkunen, & Salonen, 1996).

I’m sorry – this is why Aspergers simply give up and say, “bat-crap-crazy” neurotypicals…again.

There is a compulsion on the part of neurotypical “magic word thinkers” to take the most specific “aspects of thought and behavior” in human beings and to suddenly be possessed by the “demon of cognitive diarrhea”. Concrete thinking is utterly lacking. Analysis is unknown mental territory. Intellectual self-discipline is an “unimaginable” skill.

 Acres of blah, blah, blah skipped:

Conclusions

The construct of alexithymia is, in our opinion, a welcome addition that broadens our understanding of emotions, affect regulation, and the etiology and treatment of medical and psychological disorders. There is now a voluminous literature on alexithymia, and it is time that the construct makes inroads into clinical practice. The assessment of alexithymia in medical and mental health settings is both feasible and recommended, multiple measures of alexithymia using different methods are currently available, and the literature supports a number of useful clinical inferences when elevated alexithymia scores are found. Knowing a patient’s level of alexithymia guides our understanding of health status, clinical presentation, behavior, and responses to treatment. Although there remain various interpretive and conceptual limitations, we encourage readers to translate empirical and theoretical knowledge about alexithymia into clinical practice.

Acknowledgments

Preparation of this article was supported, in part, by a Clinical Science Award from the Arthritis Foundation and NIH grants AR049059 and AG009203.

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