Peter R. Martin: Historical Vocabulary of Addiction, Vol. II
Alexithymic
According to the electronic version of the Oxford English Dictionary (OED), the noun and adjective alexithymic is a borrowing from Greek, combined with English elements. The word comprises the prefix a- (used for forming nouns and adjectives, with the sense “without”; “not”; “-less”), the ancient Greek λέξις (speech) + θυμός (soul) and the suffix -ic (representing French ‑ique, in Greek one of the commonest of suffixes, forming adjectives, with the sense “after the manner of,” “of the nature of,” “pertaining to,” “of”). The Greek American psychiatrist Peter Emanuel Sifneos (1920—2008), known for his pioneering work in brief psychotherapy and psychosomatic medicine, coined the term alexithymic to represent a personality trait characterized by difficulty in identifying and expressing emotions. Over the years, this human attribute has acquired widespread use in Psychology and Psychiatry, including the field of addiction.
The definition of the adjective alexithymic in OED is: “Affected with alexithymia; of or relating to alexithymia.” The OED definition of alexithymia itself is: “The inability to recognize one's own emotions and to express them, especially in words.” An early example of the use by Sifneos of alexithymic as an adjective is found in his Short-term Psychotherapy (Sifneos 1972): “Schizophrenic patients who are notorious for having ‘a lack of affect’ can at times have violent emotional explosions... The ability, then, not only to recognize and express emotions but also to verbalize them is significant... I would like to introduce the term alexithymic... to describe patients who present these difficulties.” Thus, the initial use of the term was to describe phenomenology of a serious mental disorder (schizophrenia). However, it quickly acquired a much broader application in psychiatry (Sifneos 1973):
“These alexithymic characteristics not only seem to be present quite often in patients suffering from psychosomatic disorders, but also defy our usual psychodynamic ways of understanding psychological processes in general, and psychosomatic diseases in particular. Possibly because they may be due to neurophysiological, neuroanatomical, biochemical defects, or developmental difficulties involving the learning process, they require a systematic investigation. Only after the etiological factors which are responsible for these defects are clearly understood, shall we be able to develop appropriate treatment modalities to correct these broad emotional difficulties.”
he currently accepted meaning of alexithymia is easily appreciated (at least for those who are familiar with this famed American motion picture leading man) from a quote that appeared in the New York Times (Marin 1993): “Another... psychologist... is credited with rediscovering what has become a widely used clinical term for the phenomenon: ‘Alexithymia’. (Translation: No words for feelings. Movie translation: It's not O.K. to be Gary Cooper anymore.)”
The OED definition of alexithymic as a noun is: “An alexithymic person.” An early example of the word’s use is found in the Journal of Altered States of Consciousness (Anonymous 1978): “This outcome suggests a lack of right hemisphere processing of painful stimuli may contribute to the alexithymic’s characteristic psychosomatic symptoms.” This quotation implies that specific brain dysfunction may be associated with alexithymia, reflecting the emerging strategy in biological psychiatry of the era, namely, the desire to identify neurobiologic rather than purely psychodynamic explanations for personality characteristics.
To this end, an early experiment addressing the neurobiology of alexithymia measured oxygen consumption in normal and alexithymic subjects in response to affect-provoking thoughts (Nemiah, Sifneos and Apfel-Savitz 1977). Although the results of the study were deemed inconclusive by the authors, it is very likely that this may not have been the outcome if the study had been performed with modern technology (see below).
Another early study of subjective and physiological stress response patterns in normal individuals with high or low alexithymic characteristics (Martin and Pihl 1986) was motivated by the work on stress responses by Selye (1946). The findings revealed that subjects with highest alexithymic characteristics appeared to manifest elevated levels of sympathetic activity and a dissociation between subjective experience and physiological stress responses.
Finally, of the early quotes, the very broad range of consequences of the alexithymic trait is implied in Law and Philosophy (Ainslie 2000): “Alexithymics can’t use the richest strategy available for maximizing emotional reward, the cultivation of human relationships.” This statement refers to perhaps the greatest limitation experienced by alexithymic individuals, namely they do not have the capacity to access human relationships. Instead, they may find reward through other means, as addiction to drugs or problematic out-of-control behaviors, poor substitutes, indeed (Martin 2021b, 2023).
Conceptualizations of alexithymia have progressed a great deal from the notion of a deficit in the capacity of an individual “to recognize” and “to express” their emotions. A veritable explosion of interest in the importance of affective experience in neuropsychiatry has led to significant advances in the understanding of this human trait and how it can contribute to a very broad range of psychopathology (Taylor 1997):
“Over the past two decades, there has been an expanding scientific interest both in the development and regulation of affects, and in the impact of dysregulated affects on mental and physical health. This interest in affects has been prompted by the development of new technologies and experimental methods for investigating brain functions, and by fascinating findings from observational studies of the infant-caregiver relationship. While the former have advanced our understanding of the brain mechanisms involved in emotions, the latter have led to reformulations of the nature, functions, and early development of affects and have important clinical implications. At the same time, the development of new measurement instruments has enabled researcher-clinicians to investigate temperamental or dispositional differences in affectivity, and to conduct empirical studies to explore the role of dysregulated affects in a variety of medical and psychiatric illnesses. Indeed, the study of affects has become an exciting interdisciplinary activity…”
While, at first blush, the word alexithymia may have seemed an ersatz concept when formulated more than 50 years ago, it has subsequently become operationalized (Lolas, de la Parra, Aronsohn et al. 1980). Therefore, validated psychometric instruments to determine alexithymic characteristic in individuals began to be employed in both research studies and clinical practice and studies of the role of alexithymia in pathogenesis of a variety of psychiatric conditions could commence (Taylor, Bagby and Parker 1991). However, until recently, most such investigations relied on psychometric measurement of alexithymic traits rather than biological markers. As to be expected, the alexithymic construct has encountered inconsistencies, attributed to discrepancies among the various psychometric scales in use to characterize and quantify the condition, but nevertheless, research has proceeded apace (Bagby, Parker and Taylor 2020; Preece, Petrova, Mehta et al. 2024).
As the understanding of alexithymia evolved, characteristics of this trait were found to be correlated with various brain functions and other biological factors as well as with psychiatric disorders and their treatment outcome. Some of the observed statistical correlates of alexithymic traits have provided clues to pathogenic mechanisms, including emotional regulation (Maniaci, Picone, van Holst et al. 2017; Burghart, Sahm, Schmidt et al. 2024), empathy (Burghart, Sahm, Schmidt et al. 2024; Li et al. 2024), social cognition (Le Berre 2019; Di Tella, Adenzato, Catmur et al. 2020; Hurel, Grall-Bronnec and Challet-Bouju 2023), anxiety perception (Palser, Palmer, Galvez-Pol et al. 2018; Baxley, Weinstock, Lustman et al. 2019), facial recognition (Butera, Kaplan, Kilroy et al. 2023), generation and mirroring of motoric functions (Van Overwalle, Manto, Cattaneo et al. 2020; Schmahmann 2023; Burghart, Sahm, Schmidt et al. 2024) and immune dysfunction influencing pain perception and coupled affective states (Guilbaud, Perrin, Curt et al. 2021) among others.
Moreover, the cognitive and affective dimensions of alexithymia were differentially reflected in brain morphology (Goerlich-Dobre, Votinov, Habel et al. 2015) with a deficit involving the anterior cingulate cortex (ACC) thought to be the neurobiological underpinning of alexithymia (Deng, Ma and Tang 2013).
Of particular interest for this discussion is that the difficulties in recognizing and expressing emotions as identified in alexithymia have been found to be a significant risk factor for development of alcoholism and other drug use disorders (Taylor, Parker and Bagby 1990; Honkalampi, Jokela, Lehto et al. 2022). Approximately half or more of individuals with alcohol use disorder exhibit alexithymic traits (Rybakowski, Ziółkowski, Zasadzka et al. 1988; Thorberg, Young, Sullivan et al. 2009).
Additionally, studies have demonstrated that individuals with alexithymia are more likely to engage in behavioral addictions, such as gambling, sex addiction, and problematic internet use (Maniaci, Picone F, van Holst et al. 2017; Blinka, Faltýnková and Rečka 2024; Gori, Topino, Gioia et al. 2024; Li, Chen, Liu et al. 2024). A recent systematic review and meta-analysis reported a stronger association of substance use disorders with emotion-related than cognition-related dimensions of alexithymia (Honkalampi, Jokela, Lehto et al. 2022).
In a cluster analysis studying the interaction of alexithymia, depression and drinking behavior, the “alexithymic subtype” of individuals with alcohol use disorder were found to have maladaptive affective and drinking symptoms that placed them at higher risk for adverse outcomes than those with the “core alcohol use disorder subtype” and the “late-onset alcohol use disorder subtype” of subjects. It is suggested, therefore, that in alexithymic individuals, pathological drinking is employed as a coping mechanism for negative affects, thereby compounding the severity of this condition, in contrast to those with alcohol use disorder without alexithymia (Kurihara, Enoki, Shinzato et al. 2024). As might be expected, worse treatment outcomes for alcohol use disorder were found in individuals with accompanying alexithymia and higher levels of alexithymia were associated with a higher rate of relapse among alcoholics after treatment (Birt, Sandor, Vaida et al. 2008).
As suggested earlier, these findings are consistent with the view that individuals with alexithymia may engage in out-of-control and self-destructive behaviors as a way to manage or distract themselves from the emotional and social shortcomings that characterize alexithymia (Ainslie 2000). Alexithymic individuals with addiction, due to the accompanying poor insight, may have difficulty recognizing how addictive disorders actually affect them and, therefore, may be less likely to seek treatment for either the alcohol/drug use disorder or for associated emotional problems. If they do seek treatment, they typically have worse outcomes than those without alexithymic traits. This may be because the goals of recovery in addiction treatment are distinctly interwoven with achieving self-understanding and empathy with others and not simply reducing alcohol/drug use (Martin 2020, 2021b), attributes that an individual with alexithymia cannot readily access.
Overall, the relationship between alexithymia and addiction is complex and multifaceted. While alexithymia may increase the risk of developing addiction, as just discussed, use of alcohol/drugs per se may also exacerbate alexithymic symptoms — stated otherwise, alexithymic traits may be either primary or secondary to addictive disorders. This was demonstrated in young adult users of both cannabis and alcohol in a study of their performance on emotion recognition tasks which objectively determine symptoms of alexithymia (Cservenka and Donahue 2024).
An association between alexithymia and cumulative childhood maltreatment and further victimization has been described (Théorêt, Hébert and Hébert 2024). Thus, alexithymia can operate analogously to trauma-induced stress in the causal role it plays in development of addictive disorders (Martin 2021a). Along these lines, autonomic reactivity elicited by performance of stressful tasks (arithmetic, watching arousing video material and giving an oral presentation) showed a decoupling between physiological and affect processing in pain disorder patients with high compared to low alexithymia scores (Kleiman, Kramer, Wegener et al. 2016). It was suggested that this finding meant that impaired coping with stress, particularly in alexithymic individuals, is closely linked with emergence of stress-sensitive disorders.
Another perspective for investigating the neurobiological underpinnings of alexithymia may emerge from studies of individuals with autism spectrum and related disorders, which manifest a shared behavioral style of restricted emotionality and impaired social interactions (Shah, Hall, Catmur et al. 2016; Butera, Kaplan, Kilroy et al. 2023; Machado, Dias and Carvalho 2024), but without the complication of alcohol/drug use (Lai, Kassee, Besney et al. 2019). It is intriguing that individuals with autism spectrum disorder were found to have brain mitochondrial dysfunction in vivo in the ACC using positron emission tomography (Kato, Yokokura, Iwabuchi et al. 2023); this is reminiscent of the neurobiological role of the ACC demonstrated in alexithymic individuals using functional magnetic resonance imaging (fMRI) (Deng, Ma and Tang 2013).
In contrast to the earliest studies of brain functioning in alexithymic individuals using gross measures of glucose utilization which were inconclusive (Nemiah Sifneos and Apfel-Savitz 1977), the newest techniques involving detection of brain oxygen level dependent (BOLD) changes (Pauling and Coryell 1936) related to performance of designated tasks using fMRI (Belliveau, Kennedy, McKinstry et al. 1991) have yielded some interesting findings. The means whereby alexithymia may be involved in pathogenesis of addictive disorders has been suggested by a brain fMRI study of reward processes (Martin 2023) in alexithymic subjects (Goerlich, Votinov, Lammertz et al. 2017). The hypothesis was that alexithymia, a trait showing a close inverse relationship with empathy (Martin 2021b), is also linked to dysfunctions of socio-emotional processing in the brain. The influence of both alexithymia and empathy on reward processing using a social incentive delay task and a monetary incentive delay task was investigated. It was found that the alexithymic trait is intimately involved in brain mechanisms of reward, namely the modulation of neural activity in brain regions of interest (ROIs) of the emotion and reward network, both during the anticipation of social and monetary rewards and in response to the receipt of monetary rewards. Interestingly, empathy did not affect reward anticipation and modulated brain activation only in response to the receipt of social rewards.
In a more recent study, the intercorrelations among interoception (perception of the internal body state), alexithymia, and empathy were studied in college students using resting-state brain fMRI scans (Li, Peng, Qin et al. 2024). The functional connectivity of the amygdala to various parts of the brain was analyzed to identify the neural substrates of alexithymia and mediation analyses were conducted to examine the effect of alexithymia and alexithymia-specific amygdala functional connectivity on the relationship between interoceptive sensibility and empathy. The results showed that higher levels of interoceptive sensibility were associated with increased cognitive empathy through weakened alexithymia. Functional connectivity analysis indicated that right basolateral amygdala-left precuneus connectivity was negatively related to alexithymia, while right basolateral amygdala-left precentral gyrus connectivity was positively related to alexithymia. This study enhances our understanding of the neurobiological underpinnings of interoception, alexithymia and empathy, all which have distinct albeit interactive roles in the pathogenesis of addictive disorders (Burghart, Sahm, Schmidt et al. 2024).
In conclusion, considerable evidence has emerged supporting a significant contributory role for the neurobiological human trait of alexithymia in the development of alcohol/drug use and behavioral addictive disorders. Furthermore, this emotional characteristic when found in individuals suffering from addictive disorders can significantly interfere with recovery processes that are important elements of treatment. It is noteworthy that treatment of addictive disorders has long involved the development of empathy for others who also suffer with addiction and empathy seems to be inversely related to alexithymic traits in terms of their neurobiological underpinnings. This suggests that by increasing empathy, one may diminish alexithymic traits to some degree. However, the contemporary goals of recovery may be particularly difficult for individuals with significant alexithymic traits to access. For these individuals alternate treatment approaches than those based on empathy may be needed or typical treatment approaches might be augmented using other strategies (Li, Howard, Garland et al. 2017).
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